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Objective.To evaluate the frequency of dactylitis, enthesitis, and anterior uveitis (AU) in spondyloarthritis (SpA) associated with inflammatory bowel disease (IBD-SpA) compared with other SpA, and to assess the role of associated psoriasis in the occurrence of dactylitis and enthesitis.Methods.In a 12-month case-control study, the frequency of dactylitis and enthesitis in 29 patients with ulcerative colitis (UC) and 59 with Crohn disease (CD) who satisfied the Spondyloarthritis international Society criteria for axial or peripheral SpA was compared with 176 controls, including 97 (55.1%) with psoriatic arthritis (PsA), 47 (26.7%) with ankylosing spondylitis (AS), and 32 (18.2%) with nonradiographic axial SpA (nr-axSpA). The occurrence of these features in IBD-SpA with and without psoriasis was also evaluated.Results.Axial, peripheral, or mixed involvement was observed in 46 (52%), 29 (33%), and 13 (15%) patients, respectively; and 14/88 (16%) had psoriasis. Dactylitis was recorded in 4/88 patients (4.5%) with IBD-SpA and in 30 controls (17.4%; p = 0.008), enthesitis in 16 cases (18.1%) and in 78/176 controls (44.3%; p < 0.001), and AU in 3 patients (3.4%) with IBD-SpA and in 26 controls (14.7%; p = 0.01). No significant differences were found between patients with UC-SpA and those with CD-SpA. Dactylitis and enthesitis were significantly more common in patients with IBD-SpA who also had psoriasis compared to those without skin disease (p = 0.009 and 0.003, respectively).Conclusion.Dactylitis, enthesitis, and AU are significantly less frequent in IBD-SpA compared with other types of SpA. Given the frequent association of psoriasis and IBD, overlooking coexistent skin disease may lead to overestimating the frequency of these features.

Objective A multidisciplinary expert panel, the Italian board for the TAilored BIOlogic therapy (ITABIO), was constituted to formulate evidence-based decisional statements for the first-line tailored biologic therapy in patient with rheumatoid arthritis (RA), spondyloarthritis (SpA), and psoriatic arthritis (PsA). Methods Systematic review of the literature to identify English-language articles on the variables influencing the first-line biologic choice, including the efficacy and safety of the drug, the route of administration, the availability of response predictor biomarkers, the need of monotherapy, the patient socio-economic status, lifestyle, cultural level, personality, fertility and childbearing potential in women, the presence of comorbidities, the host-related risk factors for infection and latent tuberculosis infection (LTBI) reactivation, the cardiovascular (CV) risk, and costs. Results Some variables, including the patients’ preference, the indication for anti-TNF monotherapy in potential childbearing women, and the intravenous route with dose titration in obese subjects resulted valid for all the three rheumatic conditions. Further, evidence of a better cost-effectiveness profile for etanercept (ETN) and biosimilar infliximab (IFX) in RA was found. Any biologic may be employed in absence of choice driving factors in RA. Otherwise, a high infection risk or LTBI positivity drive the choice toward abatacept (ABA), tocilizumab (TCZ), or ETN. TCZ should be the first choice if monotherapy is required. High rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) titers should drive the choice toward TCZ or ABA, while in patients at high CVD risk anti-TNF choice, with preference for ETN, seems appropriate. Presence of anterior uveitis or inflammatory bowel disease drives the choice to monoclonal antibody anti-TNFs (MoAb anti-TNFs). In PsA, ustekinumab (UTK), and to a lesser extent ETN, represents the first choice in patients at high infection and TB risk. Anti-TNFs or UTK choice is guided by skin or articular disease severity, enthesitis, and dactylitis, whereas ETN should be preferred if metabolic syndrome or high CV risk complicate PsA. Conclusion Taking in account of multiple choice driving variables, first-line biologic therapy may be optimized in patients with RA, SpA, and PsA.

Background Asbestosis is characterized by lung and pleural fibrosis and by immune system dysregulation, with autoantibody production and systemic immune-mediated disease. No specific therapies are available for asbestosis. Recently, the pivotal pathogenic role exerted by interleukin-1beta has been recently reported. Case presentation We treated with anti-interleukin 1 beta targeted antibody canakinumab a 67 year old man with asbestosis and long lasting systemic autoimmune features. A dramatic improvement in clinical manifestations was observed at 1 week after the first injection, with complete clinical remission at 4 months. Conclusion This case suggests new perspectives for the treatment of asbestosis and its systemic features.

Background Musculoskeletal involvement, preferentially affecting hands and feet, represents a frequent feature and may lead to disability in patients with systemic sclerosis (SSc). The most common manifestations are arthralgia, stiffness, synovitis, and tenosynovitis. In a large multicentre study, synovitis, tendon friction rubs, and joint contractures were found in 16%, 11%, and 31% of 7286 SSc patients assessed by clinical examination 1 . However, several ultrasound (US) studies revealed a higher frequency of hand joint involvement 2 . Objectives To investigate the frequency and severity of hand joint involvement in a cohort of SSc patients evaluated by US, and to compare the results of US synovitis detection with those of physical examination. Methods Over a 6-month period, all consecutive (new and old diagnosis) SSc patients (ACR/EULAR 2013 criteria) currently followed in our center underwent clinical and US hand examination. One rheumatologist expert in musculoskeletal US performed all examinations by using Esaote Technos MPX, MyLab 40, employing high frequency (12–18 MHz) transducers. Power Doppler (PD) parameters were adjusted (range of pulse repetition frequency 400–800 Hz; frequency 7–11.1 MHz). Patients were scheduled to be examined at the same hour of the day in the same room with an ambient temperature of 21°C. Hand and wrist joints were evaluated for synovitis, tenosynovitis, calcinosis, acro-osteolysis and distal vascularization. An independent rheumatologist made the clinical examination and US examiner was blind to clinical findings. US assessment of synovitis was scored according to the OMERACT–EULAR PD composite semiquantitative scale (0–3). Results 89 patients, 79F/10M, mean age 61.11±15.1, median disease duration 160 months (min: 2,max: 492), 83 (93%) with limited SSc and 6 (7%) with diffuse SSc were recruited. Synovitis was detected in 15 (16.8%) and in 35 (40.2%) of the cases by clinical examination and US, respectively (p=0.019). PD revealed grade 1 synovitis in 19/35 (54.3%) patients, grade 2 in 14 (40%) and grade 3 in 2 (5.7%). Tenosynovitis, calcinosis and acro-osteolysis were found at US 19 (21.3%), 14 (15.7%), acro-osteolysis in 11 (12.3%) and 8 (9%), respectively. Distal vascularization was detected in 60 patients (67%). Conclusions Confirming previous studies, our results show that hand synovitis in SSc may be underestimated by clinical examination only, while US examination provides an accurate assessment of the frequency and the degree of severity of synovial inflammation. However, synovitis in our cohort of SSc patients resulted mild in the majority of the cases. References Avouac J, et al. J Rheumatol. 2010;37:1488–501.2.Cuomo G, et al. Rheumatology (Oxford) 2009;48:1414–1417. Acknowledgement None Disclosure of Interest None declared

Background Dactylitis, is observed in approximate 30% of patients spodnyloarthritis (SpA),with the highest frequency in psoriatic arthritis (PsA).SpA features complicate inflammatory bowel diseases (IBD) in at least one third of the cases.The frequency of dactylitis in IBD-SpA has been assessed in a few open studies with conflicting results1,2. Objectives Primary end point: To compare the frequency of dactylitis in a clinical series of patients with IBD-associated SpA (IBD-SpA) compared with other types of SpA. Secondary end point: to evaluate the frequency of articular and extra-articular manifestations of IBD-associated SpA compared to controls. Methods 24-month case-control study. Case patients: all consecutive patients meeting the ASAS criteria for both axial and peripheral SpA,and with a diagnosis of Crohn9s disease (CD) or ulcerative colitis (UC) certified by the gastroenterologist. Controls: the 2 consecutive patients with other SpA (ASAS criteria) observed after the case patient during the same time interval. Dactylitis diagnosis was accepted if observed at visit or if certified in the past by a rheumatologist working in our center.Patients were followed by the same rheumatologist,and follow-up visits were scheduled at baseline and every 4 months.All clinical and laboratory data were recorded in a computed patients9chart. The date of the last visit constituted the end of the follow-up. Results Case patients:88 IBD-SpA patients, 29 UC and 59 CD, 42 F/46M, mean age 47.66±15.09 ys, 10 (11.3%) B27+.Mean IBD duration was 60.05±54.66 months. Controls: 176 SpA patients, 98 PsA, 46 AS, and 32 non-radiographic axial SpA (nrx-AxSpA); 89F/87M, mean age 46.35±24.88 ys. 70 (40.7%) B27+, mean disease duration of 43.21±28.34 months. In IBD-SpA axial involvement was observed in 46 (52%) patients, peripheral in 29 (33%) and mixed in 13 (15%). Peripheral SpA was oligoarticular (≤4 joints involvement) in 26/29 (90%) patients and polyarticular in 3 (10%). Psoriasis (Pso) was associated in 14/88 (16%) of the cases. Dactylitis was recorded in 4 (4.5%) of IBD-SpA patients and in 30 (17.4%) of controls with a significant statistical difference (p=0.018). Dactylitis was recorded in only 2/74 (2.7%) IBD-SpA patients without Pso (p vs controls=0.010).Also enthesitis prevalence was significantly lower in IBD-SpA occurring in 16/88 (18.1%) patients and in 78/176 (44.3%) controls (p=0.004). Enthesitis frequency was significantly higher in 14 IBD-SpA patients associating Pso (28.5%) compared with the remaining 74 cases (16.2%) (p=0.012). Dactylitis occurred in 2/29 (6.9%) and in 2/59 (3.38%) patients with UC and CD, respectively. Anterior uveitis was recorded in 3 (3.4%) IBD-SpA patients and in 26 (14.7%) controls (p=0.02). Conclusions Dactylitis and enthesitis were significantly lower in IBD-SpA patients compared to other SpA. As reported3, Pso was frequent in our cohort of IBD-SpA,and its coexistency significantly increased the frequency of enthesitis and to a lesser extent of dactylitis.Anterior uveitis was significantly less frequent in IBD-SpA compared to controls. References Salvarani C, et al. Scand J Rheumatol 2001; Alamino RP, et al. J Rheumatol.2011; Li W-Q, et al. Ann Rheum Dis 2013. Disclosure of Interest None declared

Objective.Cardiac involvement means a poor prognosis in systemic sclerosis (SSc). Conduction defects and arrhythmias are frequent in patients with SSc, and may result in sudden cardiac death. We tested whether electrophysiologic studies and implantation of cardioverter defibrillators are recommended when ventricular arrhythmias are present.Method.A cardioverter defibrillator was implanted in 10 patients with SSc who had heart involvement.Result.After 36 months, analysis of the device showed several episodes of ventricular tachycardia in 3 patients, which were promptly reverted by electrical shock delivery.Conclusion.In patients with SSc who are affected by ventricular arrhythmias, the implantation of a cardioverter defibrillator may prevent sudden cardiac death.

Objective.To assess skin elasticity in systemic sclerosis (SSc) by using a new imaging modality, ultrasound elastography (UE).Methods.Our study included 18 consecutive patients with SSc and 15 healthy controls. Modified Rodnan skin score, physical examination, and assessment of organ involvement were performed. UE was carried out on the middle forearm and on the fingers of the dominant arm. The echo signals recorded in real time during freehand operations of probe compression and relaxation produced images representing tissue elasticity, consisting of translucent colored bands superimposed on the B-mode ultrasonographic images. The color scale varied within a large band spectrum from red, indicative of soft and highly elastic tissue, to blue, which denoted hard and barely elastic tissue.Results.On the forearm of all patients, UE showed a homogeneous blue area corresponding to the dermis visualized in a B-mode ultrasonographic image; in controls, a blue pattern was never detected and a predominance of green with sporadic areas of pale blue was observed. At sequential evaluations, UE of fingers produced inconstant and changeable colored areas.Conclusion.The imaging pattern observed in the forearm of patients with SSc may represent the reduction of strain in the dermis due to loss of elasticity. The variable pattern obtained by finger evaluation demonstrated that UE can assess skin involvement in SSc only in those areas where the dermis is known to be thicker and where the bone hyperreflection is minimal. Further studies are needed to confirm our results and determine the validity of this new imaging modality.

BackgroundCurrently, assessment of dermal thickness in systemic sclerosis (SSc) is performed by palpation and assessment using the modified Rodnan skin score (mRSS).ObjectiveTo verify whether high frequency ultrasound (US) may be a reliable and a reproducible method to measure digital dermal thickness.MethodsIn 70 patients with SSc, skin thickness was evaluated with US by 2 observers at 2 different sites on the second digit of the dominant limb to determine the interobserver variability. Patients and controls were examined twice by the first observer for intraobserver variability. Patients were divided into three subgroups according to the phase of the disease (oedematous, fibrotic or atrophic).ResultsAt both examined areas, US showed a significant dermal thickening (pConclusionsUS is a reliable tool giving reproducible results, and is able to detect digital dermal thickening in SSc.

Objectives. To investigate joint involvement in SSc and its relationship with autoantibody to the hnRNP and to anti-cyclic citrullinated peptide (anti-CCP). Methods. Sera from 55 SSc patients were investigated. Joint involvement was determined by clinical, radiological and ultrasonographical evaluation. Anti-hnRNP proteins A1 and A2 (anti-hnRNP-A1/A2) antibodies were determined by immunoblotting. Anti-CCP, ACA, anti-topo I (ATA), Sm, U1-RNP, ribosomal RNP, Ro/SSA, La/SSB autoantibody and RF were determined. Results. Six patients were positive for anti-hnRNP-A2 autoantibody and two were anti-A1 positive. Eight patients had joint erosions: seven of the eight patients positive for anti-hnRNP-A2 or A1 presented articular involvement (P < 0.04) and five of the eight erosive patients were positive for either of the two autoantibodies (P < 0.02). Of the four patients positive for anti-CCP, none had anti-hnRNP but three had erosive aspects. ATAs were found in 10 patients, six of which were also positive for anti-hnRNP (P < 0.05). RF was positive in 16 patients and in seven among those with articular involvement (P < 0.04). RF was significantly associated with anti-hnRNP in patients with erosive arthritis (P < 0.02), but not with the presence of anti-hnRNP alone. Epitope mapping of the three strongest anti-hnRNP-A2-positive sera recognized the same major epitope as patients with RA. SSc patients have higher incidence of erosions and anti-hnRNP-A2/A1 positivity. RF test and anti-hnRNP had a statistically significant diagnostic value for articular involvement. Conclusions. These parameters might suggest that autoantibody to both hnRNP antigens might become a non-specific but useful marker for joint involvement in SSc patients and identify SSc patients prone to develop joint damage.