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ObjectiveTo define the role of ultrasound (US) for the assessment of patients with rheumatoid arthritis (RA) in clinical remission, including joint and tendon evaluation.MethodsA multicentre longitudinal study has been promoted by the US Study Group of the Italian Society for Rheumatology. 25 Italian centres participated, enrolling consecutive patients with RA in clinical remission. All patients underwent complete clinical assessment (demographic data, disease characteristics, laboratory exams, clinical assessment of 28 joints and patient/physician-reported outcomes) and Power Doppler (PD) US evaluation of wrist, metacarpalphalangeal joints, proximal interphalangeal joints and synovial tendons of the hands and wrists at enrolment, 6 and 12 months. The association between clinical and US variables with flare, disability and radiographic progression was evaluated by univariable and adjusted logistic regression models.Results361 patients were enrolled, the mean age was 56.20 (±13.31) years and 261 were women, with a mean disease duration of 9.75 (±8.07) years. In the 12 months follow-up, 98/326 (30.1%) patients presented a disease flare. The concurrent presence of PD positive tenosynovitis and joint synovitis predicted disease flare, with an OR (95% CI) of 2.75 (1.45 to 5.20) in crude analyses and 2.09 (1.06 to 4.13) in adjusted analyses. US variables did not predict the worsening of function or radiographic progression. US was able to predict flare at 12 months but not at 6 months.ConclusionsPD positivity in tendons and joints is an independent risk factor of flare in patients with RA in clinical remission. Musculoskeletal ultrasound evaluation is a valuable tool to monitor and help decision making in patients with RA in clinical remission.

Background Subclinical synovial inflammation detected by ultrasonography (US) in patients with rheumatoid arthritis (RA) in clinical remission relates to disease flare. The impact of tenosynovitis in this context is not known. Objectives To evaluate the association between US-detected tenosynovitis and synovitis in RA patients in clinical remission and flare over 12-months. Methods STARTER is a multicentre cohort study of the US Study Group of the Italian Society for Rheumatology. Participants were selected on the basis of a reliability exercise and the availability of high-end equipment. Patients with RA in clinical remission underwent clinical evaluation and US synovitis (-S) and tenosynovitis (-T) were assessed categorically for Grey Scale (GS) and power Doppler (PD) at 11 joints, extensor and flexor tendons in both hands and wrists. Patients were seen at 6 and 12 months. Flare within 12 months was defined as increase of >1.2 or >0.6 if final DAS28>3.2. The relationship between the presence of GS-T/-S, PD-T/-S was evaluated by logistic models, presented as odds ratios (OR) and 95% confidence interval (CI), adjusted for pre-specified confounders. Results 361 patients (72.3% f, mean age (sd) 56.1 (13.3), median disease duration (IQR) 7.1 years (3.6–13.5)) were included. 98/326 (30.6%) patients had a flare within 12 months. Considering US variables separately, only PD-S significantly predicted flare (OR 1.87 (1.12,3.14)). When the model included both –T and –S, only the concurrent presence of –T and –S predicted flare (PD-T+-S: OR 2.06 (1.04, 4.07); GS-T+-S: OR 2.27, (1.01,5.10)), while isolated –S and –T did not. Conclusions In patients with RA in clinical remission, US-detected synovial and tenosynovial inflammation identifies patients at risk of flare. US might help decisions on management in this population. Disclosure of Interest None declared

Hand joint involvement in rheumatic diseases is often precocious and predominant as compared to other skeletomuscular regions. Clinical examination not always allows for easy detection of fluid outpouring and synovial involvement, and undoubtedly does not allow to diagnose pathognomonic bone alterations of several rheumatic conditions. Articular ultrasonography is an innocuous methodology, easily reproducible and directly applied by a rheumatologist. The aim of this vignette is to present ultrasonography elementary lesions of the hand for a prompt diagnosis.

To compare the efficacy and safety of leflunomide (LEF)-anti-TNF-alpha combination therapy to methotrexate (MTX)-anti-TNF-alpha combination therapy in a group of patients with active rheumatoid arthritis (RA). We have recruited 120 patients with RA with a high disease activity despite being treated with MTX (15 mg/week) or LEF (20 mg/die) for 3 months, without side effects. In each of these patients, therapy with either MTX or LEF was continued and randomly combined with an anti-TNF-alpha drug: etanercept, infliximab, or adalimumab. Patients were assessed at study entry and at 4, 12, and at 24 weeks. The efficacy endpoints included variations in the DAS28-ESR and the ACR20, ACR50, and ACR70 responses. At each visit, any side-effect was recorded. There were no statistically significant differences in the DAS28 variations and in the ACR responses between the two groups or among the six subgroups. The number of discontinuation due to the appearance of serious side effects was higher, but not statistically significant, in the LEF-anti-TNF-alpha group than in the MTX-anti-TNF-alpha group. Other adverse events that did not necessitate the discontinuation of therapy occurred much more frequently in patients treated with MTX than in those treated with LEF. Anti-TNF-alpha drugs can be used in combination not only with MTX, but also with LEF, with the same probability of achieving significant clinical improvement in RA patients and without a significantly greater risk of serious adverse events. In contrast, it seems that combination therapy with LEF-anti-TNF-alpha is more readily tolerated than combination therapy with MTX-anti-TNF-alpha.

Objective: To assess the efficacy of Cellfood®’s therapy in the treatment of fibromyalgia. Methods: This study was a single-blind, cross-over, randomized placebo-controlled trial. Fourty female were selected from 320 cases investigated in the period 2003-2005 of june. To be included in this study, it was required that the diagnosis of fibromyalgia was made by a specialist in according to the ACR classification criteria of 1990. The patient’s age was between 35-47 years, the choice of criteria were the absence of improvements with the conventional therapy and the normality of medical check-up. The patients were divided into two different-groups of thirty-one and nine subjects, each-one (group A) treated with Cellfood® for six months in according to the Eurodream’s scheme, and each-other (group B) treated with placebo for three months and successively with Cellfood® for three months.Besides we have estimated the tender points with algometer and the health status of women with the Fibromyalgia Impact Questionnaire (FIQ) at the baseline (T0) and at three (T1) and six month (T2). Result: The group A had an appreciable improvement of the parameters at T1 statistically significant compared to the group B, while we observed a stability of they at T2 on the group A and an improvementof the parameters of the group B statistically non significant compared to each-one. Conclusion: Our result suggest that the Cellfood®’s therapy improve fibromyalgia symptoms and health-related quality of life.

According to the criteria proposed by Ryan and McCarty,1 the diagnosis of calcium pyrophosphate dihydrate (CPPD) deposition disease has been based on radiological evidence of the characteristic calcifications and on verification of the synovial liquid of CPPD crystals. Joint ultrasonography is an innocuous diagnostic technique that is well tolerated by patients, and is the elected method for observing calcified deposits in soft tissues.2 We carried out a longitudinal study, enrolling patients affected with ultrasonographic chondrocalcinosis according to previously proposed criteria3 from a sample of consecutive patients that came to our joint ultrasonography department for gonalgia (fig. 1). A total of 47 patients were identified, of which 14 had joint effusion. Figure 1 Hyperechoic deposits. Deposits (arrows) are shown that are compatible with calcium pyrophosphate dihydrate (CPPD) calcifications in the context of the synovial membrane (1), hyaline cartilage of the …

Background Efficacy and safety of etanercept 25 mg twice weekly was comparable to 50 mg once weekly in adult patients with ankylosing spondylitis (AS). We know that AS patient who were treated initially with Etanercept 25 mg twice weekly could be switched to once weekly but with increased dose per injection at 50 mg. Howeverrecent evidences suggest that etanercept 25 mg once weekly is effective enough to maintain remission for AS among korean patients. In addition discontinuation of etanercept 25 mg usually results in the relapse of disease activity but only after some weeks inAS patients in remission. Objectives To evaluate if patients with AS in remission with biweekly etanercept therapy could be switched to an every-other-week regimen,without increased dose per injection. Methods 38 patients with AS diagnosed at least from 1 year were enrolled, according to the modified 1984 New York Criteria for ASwith by minor to moderate radiographic evidence of spinal structural damage (Stage I-III). All patients had active AS (BASDAI>or=4), despite treatment with NSAIDs. Exclusion criteria included the presence of significant comorbidities, including active infection, cardiac insufficiency (NYHA class III/IV),malignancy, elevated liver enzymes, creatinine serum level >1,20 mg/l, alcohol and/or drug abuse, pregnancy, demyelinating diseases. Before being recruited for the study, patients were screenedfor latent tuberculosisandfor viral hepatitis. Patients meeting the inclusion and exclusion criteria self-administered 25 mg of etanercept (Wyett) subcutaneously twice weekly for sixteen weeks.According to the protocol,patient withclinical remission (defined as ASAS criteria and BASDAI Results All patients received for 16 weeks a dose of 25 mg twice a week.The percentage of ASAS 20 responders was 81% (31 patients). Among them, 18 (47,3%)with persistent remission (week 12 and 16) were switched to an weekly regimen without a change in dose, while the other 13continued with biweekly etanercept therapy. At week 24, 15 patients (85%) were stable and among them 14 patients (93%) had clinical efficacy at week 36 and 54. At week 24, 3 patients (15%) did not show beneficial effects and they continued with etanercept 25 mg twice a week. There were no statistically significant differences in the incidence of adverse events between the biweekly etanercept therapy group (16 pt) and the every-other-week etanercept therapy group (14 pt). Baseline characteristics associated with a major clinical response to etanercept were a shorter disease duration, younger age, raised CRP and a higher BASDAI. Conclusions Our study indicatesthat a consistent percentage of subjectswith AS (37%), differently from RA, treated with etanercept,maintains the remission also with an every-other-week regimen. Thisfinding may suggest that the AS patients in clinical remission with biweekly etanercept could be switched to an every-other-week regimen, without increased dose per injection, with relevant lowering of economic andsafety burden. Disclosure of Interest None Declared

Objective: A dire shortage of lungs for transplantation exists. We hypothesized that aggressive organ procurement organization management of lungs usually rated as unacceptable (ratio of Pao2 to inspired oxygen fraction