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Autoimmune anterior uveitis (AU) accounts for at least half of the cases of noninfectious uveitis, and similarly to spondyloarthritis (SpA), its occurrence is related to HLA-B27 positivity. AU is significantly more frequently found in HLA-B27-positive subjects with SpA and is characterized by unilateral eye involvement, marked tendency to recur with involvement of both eyes in alternate fashion, and has good prognosis in the majority of cases. The estimated frequency of SpA in patients with AU is around 50%, whereas AU in SpA has been reported in at least 30% of cases. Across the SpA disease spectrum, AU has a frequency peak of 33.4% in patients with ankylosing spondylitis, while the estimated prevalence in psoriatic arthritis (PsA) and inflammatory bowel disease-associated SpA is 2%-25%, and 25%, respectively. In early PsA, the frequency of AU has been found in 9% of patients. The wide range of prevalence reported in PsA may be explained by the variable sets of classification criteria used for patient selection and the different length of followup. AU may precede the clinical features of SpA, may be present at diagnosis, or may complicate the SpA clinical course. However, the occurrence of AU in SpA as well as AU flares has been reduced through treatment of SpA with anti-tumor necrosis factor-α agents.

Objective The occurrence of iridocyclitis (IC) in early psoriatic arthritis (PsA) has been rarely assessed. The primary end-point of this study was to evaluate the frequency of IC at onset in patients with early PsA. Methods We evaluated the frequency of IC in a clinical series of consecutive, new outpatients with early PsA observed between January 2000 and December 2009. All patients met the Classification Criteria for Psoriatic Arthritis (CASPAR) criteria for PsA and had a disease duration ≤12 months. The following clinical patterns were considered: peripheral PsA (oligoarthritis ≤4 and polyarthritis ≥5 involved joints), axial PsA and mixed. IC diagnosis was made by the ophthalmologist. Follow-up visits were scheduled at baseline and every 4 months with interval shortening in the case of urgent clinical problems. Results Two hundred and forty-two patients, 137 (57%) women and 105 (43%) men (mean age 50.33 ± 11.7 years; mean symptom duration 9.38 ± 3.1 months) were studied. One hundred and thirty-two (51%) patients had peripheral PsA, 41 (17%) axial and 69 (28%) mixed. Twenty-six episodes of IC were recorded at diagnosis in 22 (9%) patients, 17 (77.3%) female and five (22.7%) male; 11 (50%) patients had peripheral PsA, two (9.1%) axial, and nine (40.9%) mixed; 5/22 (22.7%) patients were B27-positive. IC recurred in 2/22 (9%) patients over the follow-up period. Mean follow-up duration was 51 ± 23.2 months. Dactylitis was significantly more frequent in patients with IC compared to those without this feature (P = 0.032). Conclusion IC occurred in 9% of 242 patients with early PsA with no association with the clinical pattern and B27 positivity. This frequency is higher than previously reported.

Objective: Primary: to evaluate the frequency of anemia of inflammation (AOI) in a clinical series of patients with ankylosing spondylitis (AS) requiring anti-TNF (tumor necrosis factor) agents. Secondary: to examine anti-TNF therapy-induced changes in AOI. Method: Prospective, follow-up, 6-month study of all consecutive, new patients with AS requiring anti-TNFα drugs observed between January 2004 and December 2008. AOI was defined according to WHO criteria. Primary outcome measure: the proportion of patients showing AOI at baseline. Secondary outcome measures: the proportion of patients achieving resolution of AOI at the 6-month visit; the proportion of patients achieving any improvement in haemoglobin (Hb); the proportion of patients with any improvement in blood results. Results: One hundred and six patients (42 women and 64 men; mean age: 46 years) with AS were evaluated. Sixteen of these (15%) presented with AOI at baseline. After 6 months therapy 13 patients (81%) resolved AOI while two presented an Hb level reduction. After 6 months therapy we did not find a significant statistical improvement in red blood cell numbers (P = 0.85) and transferrin (P = 0.08) levels. Hb, mean corpuscular volume (MCV), iron, ferritin, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) improved reaching statistical significance (P = 0.0002, 0.0001, 0.001, 0.014; 0.007, 0.004, respectively). Conclusion: We found 15% frequency of AOI among a selected series of patients with AS. After 6 months of anti-TNFα therapy AOI resolved in the majority of patients with significant improvement of Hb, MCV, CRP and ESR levels.

Psoriatic arthritis is an inflammatory rheumatic disorder of unknown etiology occurring in patients with psoriasis. The Classification Criteria for Psoriatic Arthritis study group has recently developed a validated set of classification criteria for psoriatic arthritis with a sensitivity of 91.4% and a specificity of 98.7%. Three main clinical patterns have been identified: oligoarticular (≤ 4 involved joints) or polyarticular (≥ 5 involved joints) peripheral disease and axial disease with or without associated peripheral arthritis. In this context distal interphalangeal arthritis and arthritis mutilans may occur. According to other reports, also in our centre, asymmetric oligoarthritis is the most frequent pattern at onset. Axial disease has been estimated between 5% and 36% of patients. It is characterized by an irregular involvement of the axial skeleton with a predilection for the cervical spine. Recurrent episodes of enthesitis and dactylitis represent a hallmark of psoriatic arthritis. In around 20% of cases distal extremity swelling with pitting edema of the hands or feet is observed. Unilateral acute iridocyclitis, usually recurrent in alternate fashion, is the most frequent extra-articular manifestation, and accelerated atherosclerosis is the prominent comorbidity. The clinical course of peripheral and axial psoriatic arthritis is usually less severe than rheumatoid arthritis and ankylosing spondylitis, respectively. Local corticosteroid injections and non-steroidal anti-inflammatory drugs are recommended in milder forms. Sulphasalazine and methotrexate are effective in peripheral psoriatic arthritis. Recent studies have provided evidence on the efficacy of anti-tumor necrosis factor-α drugs to control symptoms and to slow or arrest radiological disease progression.

Juvenile idiopathic arthritis (JIA) may cause damage to the temporomandibular joint (TMJ). In oligoarticular forms of JIA, TMJ involvement is often asymptomatic and consequently overlooked. The aim of this study was to evaluate the presence of TMJ joint effusion (JE) by ultrasonography (US) in patients with early arthritis.We examined 68 children (57 girls, 11 boys, age range 9.1-16.0 years, mean age 11.0 years) recently diagnosed with JIA. None had received any specific treatment for inflammation. Symptomatic TMJ involvement was diagnosed when one or more of the following were present: 1) recurrent pain (spontaneous or on movement of the jaw); 2) crepitation; 3) feeling of stiffness or fatigue of the jaw; 4) intermittent locking. US of the TMJ was performed in static and dynamic phases with a General Electric LOGIQ7 scanner and a linear transducer (8.5 MHz) positioned along the axis of the mandibular ramus. JE was diagnosed when the joint capsule was ≥1.5 mm thick.Forty-six out (68%) of 68 children had US evidence of TMJ effusions (bilateral in 16 [35%] cases), but only 2/46 were symptomatic.These data suggest that children with early stage oligoarticular JIA children are likely to have inflammation of the TMJs even in the absence of symptoms. US is a simple-to-use, noninvasive, radiation-free tool that can provide useful information in the assessment and follow-up of TMJ involvement in children and young adults with JIA.Sommario INTRODUZIONE: L'artrite Idiopatica giovanile (AIG) determina alterazioni a carico della testa condilare dell'articolazione temporomandibolare (ATM). Nell'esordio oligo-articolare (OA) l'interessamento dell'ATM viene spesso trascurato perchè può essere asintomatico. Lo scopo di questo studio è quello di valutare la presenza di versamento intrarticolare (V) dell'ATM, mediante esame ecografico (US), nelle fasi precoci di malattia. MATERIALE E METODI: Sono stati studiati 68 bambini (57 bambine e 11 bambini, di età compresa tra 9,1 e 16, anni, età media: 11,02 ± 4,2 mesi) con AIG ad esordio OA. I pazienti (pz) erano sintomatici quando uno dei quattro sintomi seguenti era presente: 1) dolore ricorrente (a riposo o durante il movimento di apertura della bocca); 2) presenza di scrosci articolari; 3) presenza di limitazione nell'apertura della bocca; 4) locking intermittente. US è stato eseguito su entrambe le ATM sia in fase statica che dinamica, mediante ecografo General Electric (LOGIQ7) con sonda lineare (8,5 MHz) posizionata lungo l'asse maggiore del ramo condilare. Il V era presente quando lo spessore della capsula articolare era ≥1,5 mm. RISULTATI: 46/68 (68%) hanno presentato V a carico delle ATM; in 16 (35%) il V era bilaterale. 2/46 con V erano sintomatici, mentre in 44 non erano presenti sintomi. CONCLUSIONI: Questi dati suggeriscono che un'alta percentuale di bambini e giovani adulti con AIG ad esordio OA, nella fase iniziale della malattia, presenta un interessamento flogistico delle ATM anche in assenza di sintomi. L'US, non invasivo e facilmente ripetibile, ci offre importanti informazioni sul coinvolgimento articolare delle ATM ed è risultato utile nella diagnosi all'esordio.

Juvenile Localized Scleroderma (JLS) causes functional disabilities and cosmetic deformities. Evaluation and follow-up of lesions are mandatory to understand the disease evolution. The objective of this study is to evaluate the usefulness of skin ultrasonography (US) in monitoring the response to treatment in JLS.Ten patients (age: 101,7 ± 66,2 months; 7 M, 3 F) affected by juvenile onset LS underwent sequential US exams (at baseline and after 6 months). Skin thickness was measured by using high-frequency US (18 MHz). All patients were evaluated both clinically (modified Rodnan Skin Score, mRSS) and by US (dermal thickness) at baseline and at 6 months. At baseline, 6/10 patients received 3 pulses of corticosteroids (solumedrol 30 mg/kg/day for 3 consecutive days, then oral steroids (1mg/kg), and methotrexate s.c. (15 mg/mq/week). After 6 months, 1/6 was switched to mycophenolate mofetil (25 mg/kg/day) due to inefficacy of MTX; 4/10 did not receive any further therapy.US showed a thicker dermis and a thinned hypodermis in the lesional skin areas in respect to the healthy ones (p0.05). After treatment, in seven patients a clinical improvement (decrease of mRSS) was found. In six of these patients, US showed a decrease of dermal thickness showing a correlation with clinical data. Three patients who did not receive drugs showed unmodified images and clinical findings.US can help the assessment of skin and hypodermis in JLS and can detect an improvement of the lesions.

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

Tumor necrosis factor-α (TNF-α) plays a central role in the pathogenesis of psoriasis and psoriatic arthritis (PsA). Recently, 2 expert committees provided evidence-based recommendations for the treatment of PsA. Anti-TNF-α drugs are indicated in all forms of PsA resistant to traditional therapeutic approaches. Anti-TNF-α infliximab (IFX) is an immunoglobulin G-1 antibody that binds to soluble and cell membrane-bound TNF-α with its inactivation. Confirming previous open-label studies, 2 randomized, placebo-controlled clinical trials, IMPACT and IMPACT2, have provided evidence of the efficacy and safety of IFX in the treatment of PsA as evaluated by American College of Rheumatology (ACR)20, ACR50, and ACR70 response rates. At Week 16, a significant proportion of 51 IFX-treated patients achieved ACR20, ACR50, and ACR70 responses compared to the 51 patients of the placebo arm in the IMPACT trial. In the IMPACT2 study, 58% of the IFX-treated patients and 11% of placebo patients achieved an ACR20 response (p < 0.001), and 41% and 27% of patients in the IFX group were ACR50 and ACR70 responders, compared with 4% and 2% of placebo patients, respectively. Of note, a significant inhibition of radiographic disease progression was observed in the IFX-treated group. In both trials, psoriasis improvement was recorded in more than 80% of patients receiving IFX, with a significant difference compared to placebo group. IFX was well tolerated, with no difference compared to placebo in terms of adverse events. The extension phase of these studies showed the sustained efficacy and safety of the drug.

Objective. To evaluate in SSc, the frequency of digital lesions and the morphology, characteristics, natural course and time to healing of 1614 digital ulcers (DUs). Methods. One hundred SSc patients were followed up for 4 years. In the first step, the digital lesions were observed and classified at the time of presentation [digital pitting scar (DPS); DU; calcinosis; gangrene]. In the second step, DUs were divided into subsets according to their origin and main features. In the third step, the time to healing was recorded for each DU and the influence of DU main characteristics on time to healing was also evaluated. Results. In the first step, 1614 digital lesions were observed: DPS, 712 (44.1%) lesions; DU, 785 (48.6%); calcinosis, 110 (6.8%); and gangrene, 7 (0.8%). In the second step, DUs were subsetted as follows: DU developed on DPS (8.8%), pure DU; DU developed on calcinosis (60%); DU derived from gangrene. In the third step, the mean time to healing was 25.6 (15.6) days in DPS, 76.2 (64) days in pure DU, 93.6 (59.2) days in calcinosis ulcers and 281.1 (263.3) in gangrene. Conclusions. In SSc, digital lesions are represented by DPS, DU, calcinosis and gangrene, and provide an evidence-based DU subsetting according to their origin and main characteristics. Subsetting may be helpful for a precise DU evaluation and staging, and in randomized controlled trials for a precise identification of those DUs that are to be included in therapeutic studies. © The Author 2010. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org