Peripheral Inflammatory Arthritis Research Articles

An Atypical Presentation of Parvovirus B19 Arthritis.

It is well established that acute parvovirus B19 (B19V) infection in adults is associated with peripheral inflammatory arthritis.1 Joint involvement is usually symmetric and acute, most commonly involving the knees, feet, wrists, and small joints of the hands.2.

Outcomes of undifferentiated peripheral inflammatory arthritis in real-world practice. A longitudinal cohort study.

Undifferentiated peripheral inflammatory arthritis (UPIA) may have 3 different courses, including evolution to differentiated arthritis, remaining undifferentiated, and self-limited course. The purpose of this study was to provide a real-world evidence for predictors of outcomes in UPIA in a longitudinal cohort of patients. Patients enrolled in the CTDRC-UA cohort were screened for eligibility. Inclusion criteria were: (i) having synovitis in ≥ 1 joint, (ii) not meeting the criteria of any other rheumatic disease, (iii) having at least 2 visits per year, iv) included in the cohort during the period of 2004 to 2021, and (v) having active disease at cohort entry. Two hundred and three patients who met the inclusion criteria were followed up until January 2023. Medication-free remissions occurred in 42 (20.7%) cases. In 24 (11.8%) cases, the disease met the criteria of other rheumatic diseases, of which rheumatoid arthritis (RA) was the most common. In addition, joint damage occurred in 33 (16.3%) cases. Predictors of medication-free remissions were absence of comorbidity, starting a sustained remission at≤ 6months, and having no flare. Factors associated with disease evolution to RA were anti-citrullinated peptide antibody (ACPA) positivity, non-adherence to therapy, not going into sustained remission and having flare. Delay in treatment for > 3months and being ACPA positive were the predictors of joint damage. Although the majority of UIPA cases treated with step-up combination therapy with DMARDs do not progress to RA, most require continued treatment and a few achieve medication-free remissions. Key Points • Undifferentiated peripheral inflammatory arthritis (UPIA) can progress to rheumatoid arthritis in 11% of cases; and lack of sustained remission, being anti-citrullinated peptide antibody positive, non-adherence to therapy, and having flare are its predictors. • Medication-free remissions occur in 21% of patients with UPIA; and absence of comorbidity, starting a sustained remissionat ≤ 6months, and having no flare are its predictors. • Initiating treatment in the window of opportunity may lead to a better joint outcome.

Relief of Symptoms by Early Administration of Infliximab in Patients with Suspected Spondyloarthritis: A Case Report

Low back pain is one of the most common musculoskeletal symptoms, and it can be difficult to make an accurate diagnosis based on symptoms alone. Osteitis condensans ilii (OCI) is one of the benign etiologies of low back pain and buttock pain mainly in young multiparous women. It can be diagnosed by radiological findings of the triangular sclerotic bone lesion, in the bilateral iliac bone of sacroiliac joints. Spondyloarthritis is a group of chronic inflammatory rheumatic diseases with common features, including axial and peripheral inflammatory arthritis, enthesitis, and an association with the human leukocyte antigen B27. Since both diseases may have similar clinical symptoms, the differential diagnosis may be difficult. We present a case of relief of symptoms by administration of infliximab in patients with suspected early spondyloarthritis that may be confused with OCI.

Description of Joint Alterations Observed in a Family Carrying p.Asn453Ser COMP Variant: Clinical Phenotypes, In Silico Prediction of Functional Impact on COMP Protein and Stability, and Review of the Literature.

The role of genetics in the development of osteoarthritis is well established but the molecular bases are not fully understood. Here, we describe a family carrying a germline mutation in COMP (Cartilage Oligomeric Matrix Protein) associated with three distinct phenotypes. The index case was enrolled for a familial form of idiopathic early-onset osteoarthritis. By screening potential causal genes for osteoarthritis, we identified a heterozygous missense mutation of COMP (c.1358C>T, p.Asn453Ser), absent from genome databases, located on a highly conserved residue and predicted to be deleterious. Molecular dynamics simulation suggests that the mutation destabilizes the overall COMP protein structure and consequently the calcium releases from neighboring calcium binding sites. This mutation was once reported in the literature as causal for severe multiple epiphyseal dysplasia (MED). However, no sign of dysplasia was present in the index case. The mutation was also identified in one of her brothers diagnosed with MED and secondary osteoarthritis, and in her sister affected by an atypical syndrome including peripheral inflammatory arthritis of unknown cause, without osteoarthritis nor dysplasia. This article suggests that this mutation of COMP is not only causal for idiopathic early-onset osteoarthritis or severe MED, but can also be associated to a broad phenotypic variability with always joint alterations.

Uveitis in Patients with Ankylosing Spondylitis.

There is a close correlation between ankylosing spondylitis and uveitis, other less common ocular manifestations being episcleritis and scleritis. Though the prognosis of uveitis is good, prompt treatment is required to prevent long-term complications. This study aimed to estimate the prevalence of uveitis in patients with ankylosing spondylitis who follow outpatient clinic of a tertiary care hospital. A descriptive cross-sectional study was done in medicine outpatient department of a tertiary care hospital for 6 months. Ethical clearance was obtained from the institutional review board of National Academy of Medical Sciences. Convenient sampling was done. The data collected were entered in Microsoft excel to tabulate the data and analyze the results. Out of 81 participants, 26 patients had a history of uveitis (32%). Most of the patients in this study were of 18-30 years. Uveitis was most common in patients with both axial and peripheral disease (41%) compared to those with just peripheral disease (32%). Uveitis was more common among males (32.2%) than females (31.5%). In patients with spondyloarthritis uveitis was present in 32% of the patient with more common in patient with both axial and peripheral arthritis. Timely diagnosis of uveitis in ankylosing spondylitis can prevent the sequelae with prompt treatment.

Coeliac disease is a risk factor for the development of seronegative arthritis in patients with autoimmune thyroid disease.

Hashimoto's thyroiditis is known to cluster with other systemic autoimmune disorders. Rheumatic manifestations, such as a seronegative non-erosive polyarthritis have been described. The aim of this study was to evaluate the characteristics and the prevalence of rheumatic features in thyroiditis patients, and to ascertain whether the association with systemic autoimmune disorders improved the arthritis manifestations. In total, 180 thyroiditis patients were enrolled. Major clinical and demographic characteristics have been recorded. Patients underwent a rheumatological clinical assessment and extra-articular manifestations allowing for a differential diagnosis with systemic autoimmune diseases and spondyloarthropathy. Presence of systemic autoimmune diseases was recorded. A total of 8.33% of thyroiditis patients shown a peripheral inflammatory arthritis (P = 0.002). Female gender (P = 0.042) and thyroid peroxidase (TPOAbs) positivity (P = 0.001) were more frequent. In total, 37 patients had systemic autoimmune diseases (P = 0.0003). A significant high prevalence of coeliac disease and Addison disease was found (P = 0.034 and P = 0.049, respectively). In patients with coeliac disease, the articular manifestations were more frequent (21.21%) (P = 0.001) and the risk to develop joint involvement was 2.96. Although we found an articular involvement in about one-third of thyroiditis patients, the prevalence of inflammatory arthropathy was only 8.33%. The prevalence of other coexisting autoimmune disorders was 34.26% with a significant prevalence of coeliac disease (7.41%). Thyroiditis patients with coeliac disease have an articular involvement more frequently than those without. In these patients, we have found a high risk of developing arthritis than patients with only thyroiditis, suggesting cumulative autoimmune effects in the developing articular involvement.

EP12 Chikungunga arthritis mimicking acute seronegative spondyloarthritis

Case report - IntroductionChikungunya is a tropical arbovirus transmitted by female Aedes Aegypti or Aedes Abopitus mosquitos. It is not indigenous to UK but occurs in epidemics in Africa and Asia. It often presents with pyrexia, arthralgia or arthritis, myalgia and a maculopapular rash and can mimic both peripheral and axial inflammatory arthritis as well as more common forms of viral arthritis. It can also become chronic leading to disabling symptoms. The diagnosis should be considered in all patients presenting with early inflammatory arthritis who have travelled to affected areas. Case report - Case descriptionA 57-year-old female developed sudden onset fever along with a macular rash whilst visiting South East Asia. She then developed widespread joint pains and severe inactivity stiffness, particularly affecting her ankles. The rash and fever settled after a few days, but her arthralgia persisted in her cervical spine and both small and large joints. She had a history of recurrent episcleritis and had been investigated for axial spondyloarthropathy two years previously, but MRI imaging of the spine and sacroiliac joints did not show any inflammatory changes.Examination in the rheumatology clinic confirmed right medial epicondylitis, bilateral shoulder tenderness, tenderness over the extensor tendons of the feet and painful cervical spine movement.Investigations revealed high inflammatory markers; CRP 29 (0-10 mg/L) and ESR 48 (0-15 mm/hr), a positive rheumatoid factor but negative anti CCP antibodies and a normal white cell count.Acute seronegative spondyloarthropathy was suspected but Chikungunya serology was requested at the suggestion of the patient, because of the history of a mosquito bite. IgM and IgG antibodies were positive on immunofluorescence, confirming recent infection.She was initially given intramuscular depomedrone and non-steroidal anti-inflammatory drugs (NSAIDs) with a short response but required oral prednisolone 20mg daily to suppress the inflammation in her feet. An MRI confirmed an ankle effusion and peroneal tenosynovitis. After 6 months her symptoms improved, and she was able to stop prednisolone completely and she remains well 9 months after the initial infection.Case report - DiscussionChikungunya infection causes musculoskeletal symptoms in all affected patients, but the clinical presentation can highly variable, from mild joint pain to erosive arthritis. It can be divided into three phases: incubation phase, acute phase, and chronic phase. The incubation phase varies between one to twelve days after the mosquito bite. The acute phase begins with high fever, headache, polyarthralgia/arthritis, lymphadenopathy, and anorexia. Joint involvement is often distal and symmetrical affecting the hands, wrists, shoulders, knees, ankles, and feet. A maculopapular rash is common. Dengue virus and Zika virus infection can present similarly. Treatment for acute Chikungunya fever is supportive. Analgesic, anti-pyretic and NSAIDs are used for symptom relief. During the chronic phase, infected people develop symmetrical, migratory, oligoarticular or polyarticular arthritis with morning stiffness and joint oedema, which can last from months to years.Our patient had a previous history which was consistent with seronegative spondyloarthropathy, an acute presentation of inflammatory arthritis and results and imaging which supported this diagnosis. The correct diagnosis could easily have been missed if a travel history had not been taken and the patient’s suspicions ignored.The best treatment for chronic Chikungunya arthritis is unclear. NSAIDs are often the first treatment but, as in this case systemic steroids are often necessary. Conventional synthetic DMARDs have also been reported efficacious. Biologic DMARDS have been used in resistant cases.Case report - Key learning pointsChikungunya has emerged as a global disease affecting millions of people with significant musculoskeletal morbidity. Any patient has travelled to endemic areas including Africa and Asia, with fever and joint pain should be screened for Chikungunya virus as well as Dengue virus, and Zika virus.Diagnosis is either by RT PCR (positive 0-7 days of infection or Immunoglobulin M (detectable after 5 – 10 day of infection and persists for few months).Treatment is supportive in acute phase, may require low doses of steroids to aid resolution of symptoms. Conventional DMARDS have shown benefit in chronic phase with ongoing synovitis/tenosynovitis. Patients may know more about rare, endemic diseases than their European doctors and their suspicions about potential diagnoses should always be considered.

Assessing rheumatologists' attitudes and utilization of classification criteria for ankylosing spondylitis and axial spondyloarthritis: a global effort.

This study aims to assess rheumatologists' perceptions, utilization patterns, and attitudes towards the modified New York (mNY) criteria for ankylosing spondylitis (AS) and Assessment of SpondyloArthritis International Society (ASAS) criteria for axial spondyloarthritis (axSpA). Members of the national rheumatology societies in five countries (United States of America (USA), Canada, India, Turkey, and Brazil) were invited to participate in a survey containing questions regarding rheumatologists' familiarity, and use of AS and axSpA classification criteria in daily practice, perceived specificity of spondyloarthritis features in making the diagnosis, patterns of imaging tests performed in daily practice, and their opinion about the need for modification of current classification criteria. The responses were analyzed by gender, age, years in practice, as well as by country of practice. Descriptive statistics, t test, and chi-square test were used for comparison of groups. Approximately 6% rheumatologists (478 out of 8021 professional association members) from five countries completed the survey. The country-specific response rates were Brazil 4%, USA 4.3%, India 11%, Canada 14%, and Turkey 29%, though the overall contributions from individual countries were USA 47%, India 14.9%, Brazil 13.8%, Turkey 12.8%, and Canada 8.8%. The mean age of respondents was 50years (± 11.8), 31% were females and 90% spent majority (> 75%) of their time in clinical practice. The mNY and ASAS criteria were regularly used in clinical practice by 44 and 66% of responders, respectively. Those reporting "always" using ASAS criteria were more likely to be women (p = 0.006), and within 5years of completing rheumatology training. Vast majority (74%) regarded Inflammatory Back Pain (IBP) as a specific feature for axSpA. Majority (50 and 60%, respectively) regarded uveitis and dactylitis as "very specific" features helping them make the diagnosis of axSpA, whereas heel enthesitis, peripheral inflammatory arthritis, and response to NSAIDs were considered "somewhat specific" by 50% of the responders. Less than half (47%) of the responders used the mNY grading for X-ray of SI joints. In the case of normal X-ray of SI joint, the use of MRI was more frequent than CT scan (83.6 vs. 10.9%) in assessing for sacroiliitis. If sacroiliitis was not seen on X-rays, the likelihood of ordering MRI was significantly higher among rheumatologists completing training within < 15years versus > 25years prior (90 vs. 75%, p = 0.007). Overall, 70% thought that ASAS criteria were adequately specific for clinical trials. However, 42% respondents still felt a need to modify ASAS classification criteria for axSpA. Also, 46% respondents felt that mNY criteria should be modified. In the absence of diagnostic criteria, majority of rheumatologists are using the classification criteria for diagnosis of axSpA. Though axSpA classification criteria are perceived to be specific for clinical trials, 40% rheumatologists feel the need to modify these criteria. Key Points • This study informs how rheumatologists in five countries spread over four different continents diagnose axSpA in clinical practice. • Since majority rheumatologists among survey respondents across the countries use ASAS criteria for diagnosis of axSpA, more specific criteria may be required to avoid overdiagnosis. • MRI is commonly used to rule out sacroiliitis in case of normal X-ray of sacroiliac joints.

Upper Extremity Tendon Transfers: A Brief Review of History, Common Applications, and Technical Tips.

Background Tendon transfer in the upper extremity represents a powerful tool in the armamentarium of a reconstructive surgeon in the setting of irreparable nerve injury or the anatomic loss of key portions of the muscle-tendon unit. The concept uses the redundancy/expendability of tendons by utilizing a nonessential tendon to restore the function of a lost or nonfunctional muscle-tendon unit of the upper extremity. This article does not aim to perform a comprehensive review of tendon transfers. Instead it is meant to familiarize the reader with salient historical features, common applications in the upper limb, and provide the reader with some technical tips, which may facilitate a successful tendon transfer. Learning Objectives (1) Familiarize the reader with some aspects of tendon transfer history. (2) Identify principles of tendon transfers. (3) Identify important preoperative considerations. (4) Understand the physiology of the muscle-tendon unit and the Blix curve. (5) Identify strategies for setting tension during a tendon transfer and rehabilitation strategies. Design This study was designed to review the relevant current literature and provide an expert opinion. Conclusions Tendon transfers have evolved from polio to tetraplegia to war and represent an extremely powerful technique to correct neurologic and musculotendinous deficits in a variety of patients affected by trauma, peripheral nerve palsies, cerebral palsy, stroke, and inflammatory arthritis. In the contemporary setting, these very same principles have also been very successfully applied to vascularized composite allotransplantation in the upper limb.

Assessment of the safety, tolerability and effectiveness of first Russian generic aceclofenac in patients with undifferentiated peripheral inflammatory arthritis

To evaluate the effectiveness and tolerability of the drug in patients with undifferentiated peripheral inflammatory arthritis (UPIA). We observed 60 patients (39 women and 21 men) met G. Hazlewood et al., UPIA criteria, 2011. Patients were divided into 3 groups: with monoarthritis, oligoarthritis and polyarthritis. They took aceclofenac 100 mg twice day for 3 weeks. We noted significant decreasing in pain level according to visual analogue scale: in patients with monoarthritis by 69.3 mm (p0.001); in oligoarthritis group by 47.5 mm (p0.001), in patients with polyarthritis by 30 mm (p0.001). The life quality by the EQ-5D-5L index was improved too in all groups from 0.616 to 0.829 (p0.001). The satisfaction with the therapy was: in monoarthritis patients (80% of patients and 93% of doctors noted good results), in oligoarthritis group (53% and 39% accordingly) and polyarthritis (74% and 64% respectively). We suppose the difference was due to the fact that mono- and oligoarthritis patients suffered from initial forms of seronegative spondylarthropathy, in which the effectiveness of NSAIDs is traditionally higher; polyarthritis patients probably had debut of rheumatoid arthritis. Adverse events of therapy were mild. We noted gastrointestinal tract symptoms (dyspepsia) and increased ALT in 10 patients and increased blood pressure in 1 patient. The symptoms did not require discontinuation of therapy. Сonclusion. Post-registration observational study of first Russian generic aceclofenac (Alental, Vertex, Russia) was conducted. In UPIA patients aceclofenac therapy was most effective in mono- and oligoarthritis patients. The first Russian generic aceclofenac (Alental, Vertex, Russia) has good efficacy, tolerability and safety and can be recommended for arthritis treatment.

EP12 Bilateral lipoma arborescens as a presenting feature of ankylosing spondylitis

Abstract Background Lipoma arborescens (LA) is a rare, slow growing lesion defined as a villous lipomatous proliferation of the synovial membrane with replacement of the synovial tissue by mature fatty cells. It usually involves the knee and can be associated with degenerative joint disease, trauma, diabetes mellitus and very occasionally with inflammatory arthritis. Diagnosis is made using MRI which shows a synovial mass that is isointense relative to fat and joint effusion. Histologically there is diffuse replacement of the subsynovial layer with mature adipocytes and infiltration of mononuclear cells. Treatment is with synovectomy and treating any underlying condition. Methods We present the first case bilateral knee LA as a presenting feature of ankylosing spondylitis. Results A 29-year-old Caucasian male presented to a knee orthopaedic surgeon with a two-year history of atraumatic bilateral knee swelling. He had a ten-year history of intermittent knee pain and stiffness which was unresponsive to non-steroidal anti-inflammatory drugs (NSAIDs) and physiotherapy. Examination revealed large bilateral knee effusions with restriction of movement. Plain radiographs of his knee joints showed minor osteophytic lipping laterally on his right knee. He had an MRI of both his knees which showed bilateral joint effusions and bilateral LA. He was referred to the rheumatology team for consideration of underlying inflammatory arthritis. Further questioning revealed no history of uveitis, dactylitis, psoriasis, inflammatory bowel disease but lower back pain which was long standing. Blood tests showed rheumatoid factor, anti-CCP, anti-DsDNA, ENA were negative with ANA positive in a homogenous pattern. C-reactive protein (CRP) was only slightly raised at 5.6mg/L. Knee aspirate showed mixed inflammatory cells. Radiographs of his spine showed no syndesmophytes but sacroiliac joints showed established bilateral sacroiliitis. A diagnosis of ankylosing spondylitis with secondary LA was made. He was commenced on sulfasalazine to treat his peripheral inflammatory arthritis along with continuation of NSAID. He remained symptomatic with Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score of 8 and Spinal pain VAS of 9. As he fulfilled NICE guidelines for biologic use in AS, he was commenced on adalimumab 40 mg fortnightly injections and had a good response to treatment with improvement in BASDAI, pain VAS, knee swelling and normalisation of CRP. Conclusion There have been reports of LA in association with inflammatory joint disease. This is the first case of bilateral LA as a presenting feature of ankylosing spondylitis. It has been demonstrated that LA plays a role in joint inflammation and damage through tumour necrosis factor alpha (TNFα) and matrix metalloproteinase 3 (MMP3). MMP3 is known to cause joint erosion in inflammatory joint conditions such as rheumatoid arthritis and ankylosing spondylitis. It is therefore proposed that while managing LA, looking for underlying inflammatory arthritis may provide the answer. Disclosures S. Khalid None. M. Cox None. M. Kazmi None.

O14 Semi-quantitative assessment of synovial inflammation on US guided synovial membrane biopsy is contingent to disease phase, autoimmune profile and treatment response in RA: a large single center experience

Abstract Background Ultrasound (US)-guided minimally-invasive synovial tissue (ST) biopsy is a well-tolerated procedure for basic and translational studies on chronic inflammatory joint diseases as rheumatoid arthritis (RA), psoriatic arthritis (PsA) and spondyloarthritis (SpA). The aim of the study was to evaluate the utility of histopathologic criteria to differentiate US-guided ST biopsies in daily clinical care in relation to diagnosis, disease characteristics, US parameters and treatment response in a large single center ST biopsy unit. Methods 1,064 patients [545 RA, 167 PsA, 75 SpA, 199 undifferentiated peripheral inflammatory arthritis (UPIA), 18 crystal arthritis, 26 connective tissue diseases and 34 osteoarthritis (OA) respectively] who underwent US-guided ST biopsy were enrolled. US parameters (Synovial Hyperthrophy and Power Doppler signal respectively) were recorded for each biopsied joint. RA, PsA and SpA patients were stratified based on disease activity phase (naive to DMARDs, DMARDs resistant and in sustained remission, respectively). Clinical, demographic and immunological characteristics were recorded for each patient. All ST FFPE specimens were routinely processed and stained with H&amp;E and classified by a pathologist, blinded to clinical characteristics, using the Krenn score to assess the degree of ST inflammation. Moreover, the presence/absence of lymphocytes, plasmacells, granulocytes and oedema was assessed for each ST. All naive to treatment RA were treated according to the T2T scheme and followed for at least 12 months and DAS remission rate was recorded. Results In the cohort, the distribution of synovitis score was significantly different among patients with inflammatory chronic diseases (RA, PsA, SpA and UPIA respectively) compared to OA (ANOVA Test p &amp;lt; 0.001). Moreover, Krenn score directly correlated with synovial hyperthrophy (R = 0.36; p &amp;lt; 0.001) and Power Doppler signal (R = 0.40;p&amp;lt;0.001) of the biopsied joint. Considering the RA cohort, naive RA showed a higher Krenn score compared to resistant RA (p &amp;lt; 0.001) and RA in sustained clinical and US remission (p &amp;lt; 0.001), directly correlating with DAS28 (R = 0.51; p &amp;lt; 0.001). Moreover, ACPA and RF positivity was related to the Krenn score and to ST plasmacells presence at RA onset (p &amp;lt; 0.05 and p &amp;lt; 0.001, respectively) but not at the time of DMARDs-failure or sustained remission achievement (p &amp;gt; 0.05 for both). Stratifying naive RA based on disease duration at ST biopsy, naive RA with symptoms duration &amp;gt;1 year, showed higher Krenn score compared to those with symptoms duration &amp;lt;3 months (p &amp;lt; 0.001). Finally, logistic regression analysis revealed that Krenn score higher or equal to 4.5 at baseline is an independent factor of no DAS remission achievement within 12 months [OR(95%CI):0.37(0.20-0.67)p&amp;lt;0.001] in naive RA. Conclusion Krenn score is a reliable tool for the semi-quantitative assessment of ST inflammation on US-guided ST biopsies being differentially distributed among various chronic inflammatory joint diseases and contingent to disease phase, autoimmune profile and therapeutic response in RA. Disclosures S. Alivernini None. B. Tolusso None. M. Gessi None. M. Gigante None. L. Petricca None. C. Di Mario None. S. Perniola None. A. Fedele None. G. Peluso None. L. Bui None. A. Capacci None. F. Federico None. G. Ferraccioli None. E. Gremese None.

Psoriatic arthritis: A permanent new challenge for dermatologists (Review).

Considering that most of the patients (>2/3) are diagnosed with psoriasis in the cutaneous form long before the joint damage occurs and, in these conditions, a significant proportion of them is found in the dermatologist's initial records, a question must be asked: when is it necessary to send these patients to a rheumatology consultation? The recognition of psoriatic arthritis in patients with vulgar psoriasis and the dermatologist's ability to differentiate it from other arthritis, offers the opportunity to improve patient prognosis by prompt intervention and close collaboration with the rheumatologist. Diagnosis of early psoriatic arthropathy should be considered when a patient with psoriasis or family history of psoriasis has peripheral inflammatory arthritis (oligoarthritis or distal interphalangeal joints damage), enthesitis, dactylitis, spinal pain of inflammatory type. Given that patients with psoriasis are included in the dermatologists' medical records, it is very important to recognize psoriatic arthritis in patients with cutaneous psoriasis, to differentiate it from other possible arthritis, thus having the possibility to improve patient prognosis by prompt intervention and through collaboration with the rheumatologist.

Synovial Predictors of Differentiation to Definite Arthritis in Patients With Seronegative Undifferentiated Peripheral Inflammatory Arthritis: microRNA Signature, Histological, and Ultrasound Features.

Objectives: To examine synovial tissue (ST) predictors of clinical differentiation in patients with seronegative undifferentiated peripheral inflammatory arthritis (UPIA).Methods: Fourty-two patients with IgA/IgM-Rheumatoid Factor and anti-citrullinated peptide antibodies negative UPIA, naive to Disease-Modifying Anti-Rheumatic Drugs, underwent Gray Scale (GSUS) and power Doppler (PDUS) evaluation and Ultrasound (US) guided ST biopsy. CD68, CD3, CD21, CD20, and CD31 synovial expression was evaluated by immunohistochemistry. Whole ST microRNA expression was assessed using miScript miRNA PCR Array. Peripheral blood (PB) and synovial fluid (SF) IL-6, VEGF-A, and VEGF-D levels were measured by ELISA and ST TNF expression was assessed by RT-PCR. Each patient was prospectively monitored and classified at baseline and within 1 year as UPIA, Rheumatoid Arthritis (RA), Spondyloarthritis (SpA) or Psoriatic Arthritis (PsA), respectively.Results: At baseline, CD68+ cells were the most common cells within the lining layer (p < 0.001) in seronegative UPIA, directly correlating with GSUS (R = 0.36; p = 0.02) and PDUS (R = 0.55; p < 0.001). Synovial CD31+ vessels count directly correlated with GSUS (R = 0.41; p = 0.01) and PDUS (R = 0.52; p < 0.001). During the follow-up, 6 (14.3%) UPIA reached a definite diagnosis (2 RA, 2 SpA and 2 PsA, respectively). At baseline, UPIA who differentiated had higher GSUS (p = 0.01), PDUS scores (p = 0.02) and higher histological scores for CD68+ (p = 0.005 and p = 0.04 for lining and sublining respectively), sublining CD3+ cells (p = 0.002), CD31+ vessels count (p < 0.001) and higher IL-6 PB levels (p = 0.01) than patients who remained as UPIA. MiRNA PCR Array showed that among the 86 tested miRNA species, at baseline, miR-346 and miR-214 were significantly down-regulated (p = 0.02 for both) in ST of UPIA who differentiated than in patients who remained as UPIA, inversely correlating with the lining CD68+ cells IHC score (R = −0.641; p = 0.048) and CD31+ vessels count (R = −0.665; p = 0.036) and with higher baseline ST expression of TNF (p = 0.014). Finally, logistic regression analysis demonstrated that baseline GSUS and PDUS scores ≥1.5 [OR:22.93 (95%CI:0.98–534.30)] and CD31+ vessels count ≥24.3 [OR:23.66 (95%CI:1.50–373.02)] were independent factors associated with the development of definite arthritis.Conclusions: MiRNA signature, histological and US features of ST may help in the identification of seronegative UPIA with high likelihood of clinical differentiation toward definite seronegative arthritis.

Performance of Two Screening Questionnaires for Inflammatory Arthritis in Patients with Inflammatory Bowel Disease.

Musculoskeletal symptoms are the most common extraintestinal manifestations of inflammatory bowel disease (IBD). An essential step in the management of these patients is to establish referral algorithms through the use of appropriate screening tools. Our objective was to evaluate the performance of two simple questionnaires to detect inflammatory arthritis (IA) in patients with IBD. Two questionnaires, one for detecting axial IA and the other for peripheral IA, were tested among 112 IBD unselected consecutive patients of both sexes, aged 18–45 years. The study period was from January to December 2016. Each questionnaire was composed of three simple questions. If the patient answered affirmatively at least to two of the three questions, the questionnaire was considered positive. Clinical diagnosis of IA based on an expert's opinion was the reference gold standard. To obtain a weighted value of sensitivity and specificity, likelihood ratio (LR) values were calculated. Twenty-seven percent of the patients were considered positive responders to the axial questionnaire while 32% were considered positive responders to the peripheral questionnaire. Twenty-four patients (21.4%) were diagnosed with axial IA, whereas 26% had peripheral IA. The axial questionnaire yielded a sensitivity of 87.5% (67.6–97.3), specificity of 89.8% (81.5–92.2) and LR+ of 8.6 (4.5–16.2). For the peripheral questionnaire, these values were 82.8% (64.2–94.2), 87.4% (79–93.3), and 6.6 (3.8–11.4), respectively. Both questionnaires showed an adequate screening capacity for IA in patients with IBD. Their specificity, together with their simplicity, can make them suitable detection tools in gastroenterology and general medicine consultations.

Sharing Ongoing Care with Primary Care Physicians Opens Up Opportunity for Timelier and Earlier Care by Rheumatologists for Patients with New Inflammatory Polyarthritis.

In our region in Quebec, Canada, access to rheumatologists is very limited. Sharing followup of stable patients with their primary care physicians (PCP) could increase access to rheumatologists. In our study, we assessed the feasibility and potential benefits of sharing followup of inflammatory arthritis (IA) patients with their PCP. We reviewed the clinical records of 300 patients with peripheral arthritis who presented at our rheumatology outpatient clinic between July and October 2015. We distributed questionnaires to their treating rheumatologist, asking whether a PCP could participate in the followup of the patient and whether there were any factors that would prevent shared followup. We also distributed questionnaires to PCP to assess their level of comfort in participating in the followup care of patients with arthritis. Chart review was completed on 300 patients. There was no treatment modification in 49% of the cases, and 38% of the visits were deemed unnecessary by the attending rheumatologist. We found that 74% of PCP were very interested in sharing the arthritis followup care of their patients. According to PCP, the main barriers to shared followup were treatment with biological agents, active disease, and need for infiltrations. Main organizational barriers were the lack of rheumatologist availability to see patients urgently (46%) and the lack of clear guidelines for the management of IA (58%). Up to 38% of peripheral IA visits to a rheumatologist could have been prevented and done by a PCP. In our department, this represented up to 19 followup visits per week that could have been avoided by involving a PCP.

SP0019 How to Use MRI in Inflammatory Arthritis in Clinical Practice

This presentation reviews the utility of MRI in the diagnostic workout of suspected and undifferentiated axial and peripheral inflammatory arthritis. Furthermore it briefly describes how magnetic resonance imaging (MRI) can...

Present Role of Positron Emission Tomography in the Diagnosis and Monitoring of Peripheral Inflammatory Arthritis: A Systematic Review

To determine the current status of positron emission tomography (PET) as a tool for diagnosis and monitoring of peripheral inflammatory arthritis (IA). For conducting this systematic review, the PubMed (Medline), Embase, and Cochrane Library databases were searched until December 31, 2012. Studies of PET for diagnosis and/or therapy monitoring of peripheral IA were included. Data were summarized qualitatively using best evidence synthesis. Eighteen articles met our inclusion criteria. The majority of studies were feasibility studies with varying methods applied. All studies demonstrated that PET visualized IA with high sensitivity, corresponding to clinical assessments. PET outcome of clinically active IA also matched that of ultrasound and magnetic resonance imaging. PET differentiates from other modalities by (quantitative) imaging of molecular sites in the synovium. The first studies reporting on the potential clinical applications of PET to image subclinical synovitis in preclinical RA and during therapy have been published. The results are promising, but the number and study populations of these studies are still limited. Thus far, a limited number of PET studies addressing IA imaging have been published. The PET modality seems to offer highly sensitive and potentially specific imaging of IA at the (quantitative) molecular level. Clinical application studies for early diagnostics and therapy monitoring are arising, but these topics should be further explored in future studies with larger cohorts. For integration in clinical practice, aspects such as radiation burden and cost-effectiveness should also be taken into account.

Australian and New Zealand national evidence-based recommendations for the investigation and follow-up of undifferentiated peripheral inflammatory arthritis: an integration of systematic literature research and rheumatological expert opinion

To develop Australian and New Zealand (ANZ) recommendations for the investigation and follow-up of undifferentiated peripheral inflammatory arthritis (UPIA) using an evidence-based approach. Ten questions pertaining to the investigation and follow-up of patients with UPIA in daily rheumatological practice were defined by clinicians using a modified Delphi approach. A systematic literature search was conducted for each of the final questions. The results were presented to a workshop of 54 ANZ rheumatologists in May 2009. Discussions were held to develop consensus statements for each question, based on published evidence and clinical experience/expertise. Ten recommendations were made on diagnostic value of clinical features in the patient's history and examination, predictors of poor prognosis and persistence, synovial fluid analysis, serology, imaging and human leukocyte antigen B27 testing. The lack of specific research to inform recommendations presented a challenge. Dynamic discussion groups outlined individual experience in areas without good quality clinical trial evidence. The median strength of support for the final set of recommendations was 7/10 (interquartile range 6-8), ranging from 6 to 9 for individual statements. Ten ANZ recommendations for the investigation and follow-up of UPIA were formulated, based on available evidence and extensive clinical experience. The systematic literature review was of limited value while animated discussion of individual experience, with subsequent information exchange, highlighted the importance of merging clinical expertise with published literature to establish practical recommendations that can improve quality of care in rheumatology.

Achievement of sustained deep remission with adalimumab in a patient with both refractory ulcerative colitis and seronegative erosive rheumatoid arthritis

Inflammatory bowel disease (IBD) is commonly associated with peripheral inflammatory arthritis, and it has been estimated that as many as 12% of IBD patients report these manifestations. However, rheumatoid arthritis (RA) is rarely associated with ulcerative colitis (UC). Among all the biological agents available, nine have been currently approved for the treatment of RA. Conversely, only Infliximab and recently Adalimumab have been approved for UC. In particular, the efficacy of Adalimumab in UC has been demonstrated by both recent randomized controlled trials and real-life studies. Moreover, Adalimumab is a well-established treatment for RA. Herein, we describe a patient with RA and UC treated successfully with ADA.