summaryThe objective of this prospective study was to investigate the transition from primary (PRP) to secondary (SRP) Raynaud's phenomenon (RP), in a large cohort of patients affected by isolated RP. A total of 2065 patients with RP were investigated by clinical interview, laboratory examinations, and nailfold videocapillaroscopy (NVC). Patients with negative NVC at first visit were yearly followed to monitor either the appearance of specific morphological alterations at NVC, or clinical manifestations of an underlying disease. Capillary abnormalities at NVC were scored, as well as the qualitative patterns of microangiopathy (Early, Active and Late). NVC was found negative at first visit in 1500 subjects; among them, 412 patients were evaluable and they were followed for a mean time of 5±4 years (range 2-13 years). Sixty-eight patients (16%) achieved a diagnosis of SRP during follow-up, showing normal or not specific capillary alterations at NVC 4% of patients (the diagnosis was undifferentiated connective tissue diseases), Early scleroderma-pattern 57%, Active sclerodermapattern 7%, Late scleroderma-pattern 12%, and scleroderma-like pattern 18% of patients. The time of transition from normal/not specific capillary alterations to Early scleroderma-pattern was 4.4±3.8 years. Enlarged capillaries (diameter between 20 and 50 microns) and mild reduction of capillary density were found the more frequent markers at first NVC visit in patients who progressed to a scleroderma pattern (P=0.01). This study demonstrates in a large cohort, that almost 16% of patients initially diagnosed as affected by RP with negative NVC may transit to SRP during a mean follow-up of 4.4 years. PRP patients showing major notspecific alterations of nailfold capillaries at first NVC should be strictly monitored at least once a year since at higher risk of transition to SRP.

summaryThe objective of this review is to update the recommendations of the 2010 Italian Consensus on the use of methotrexate (MTX) in rheumatoid arthritis (RA) and other rheumatic diseases. The literature published between 2008 and 2012 was systematically reviewed and updated recommendations on MTX use in rheumatic diseases, particularly RA, were formulated. These recommendations were approved by a panel of expert Italian Rheumatologists. A total of 10,238 references were identified, among which 70 studies were selected for critical evaluation. Sufficient evidence had accumulated to warrant changes to several of the recommendations in the new version. A new recommendation for patients with RA who are in MTX-induced clinical remission was also proposed and approved by the panel. Updated recommendations for the use of MTX in patients with RA or other rheumatologic disease are proposed.

Background Systemic sclerosis (SSc) is characterized by decreased peripheral blood perfusion (BP) and increased dermal thickness (DT) (1-3). Objectives The aim of this study was to identify possible correlations between BP and DT in three different areas of skin (periungual, dorsum of hand and zygoma) in SSc patients. Methods Sixty-three SSc patients (mean age 64±11SD years) were enrolled after written informed consent. BP was analysed by new technique laser speckle contrast analysis (LASCA) at the level of dorsal region of hands and face in both SSc patients and healthy subjects (4). Different regions of interest (ROI) were created at level of periungual areas of the 3rd finger bilaterally, dorsum of both hands and zygomas, and the average BP was scored as perfusion units (PU). Both high frequency ultrasound (US) and modified Rodnan skin score (mRss) were used to evaluate average DT at the level of dorsum of 3rd finger, hand and zygoma bilaterally (5). US and LASCA were also performed in 63 age and sex matched healthy subjects. Statistical evaluation was carried out by non parametric tests. Results A negative correlation was observed between BP and both ultrasound-DT (p=0.0005) and mRss (p=0.007) in SSc patients at the level of fingers. No statistically significant correlation was found between BP and both ultrasound-DT and mRss at level of dorsum of hands and zygomas in SSc patients. In healthy subjects no statistically significant correlation was detected between BP and DT evaluated by both US and mRss at the level of fingers, dorsum of hands or zygomas. SSc patients showed a statistically significant lower BP at level of periungual areas when compared with healthy subjects (p<0.0001). No statistically significant difference in BP values was observed between SSc and healthy subjects at the level of dorsum of hand and zygomas. SSc patients showed a statistically significant higher ultrasound-DT at the level of periungual areas, dorsum of hands and zygomas than healthy subjects (p<0.0001, for all). A statistically significant positive correlation was observed between ultrasound and mRss concerning DT evaluation in SSc patients at level of the three areas (periungual p<0.0001; dorsum of hand p=0.03; zygoma p=0.0001). Conclusions This study demonstrates a relationship between periungual BP evaluated by LASCA and finger DT evaluated by both US and mRss in SSc patients. SSc patients have a statistically significant higher DT at level of dorsum of finger, hand or zygoma than healthy subjects. There is a significant positive correlation between US and mRss in the assessment of DT. References Cutolo M, et al. J Rheumatol 2010; 37:1174-80. Rosato E, et al. Rheumatology 2011;50:1654-8. Moore TL, et al. Rheumatology 2003; 42: 1559-63. Draijer M et al. Laser Med Sci 2009; 24: 639-51. Kaloudi O et al. Ann Rheum Dis. 2010; 69:1140-3. Disclosure of Interest None Declared

Background Peripheral microangiopathy and increased dermal thickness (DT) are typical clinical aspects of systemic sclerosis (SSc) (1-3). Objectives The aim of this study was to identify and score possible correlations between nailfold microangiopathy severity and finger DT in systemic sclerosis (SSc) patients. Methods Fifty-five SSc patients (mean age 54±12SD years, disease duration 6±5 years) and 42 healthy subjects were enrolled, after informed consent. All patients were evaluated by nailfold videocapillaroscopy (NVC) to classify and score the severity of microangiopathy. The appropriate NVC pattern was assigned to the SSc patients (“early”, “active” and “late”), and the microangiopathy evolution score (MES) was also calculated (1,4-5). Both modified Rodnan skin score (mRss), and high frequency skin ultrasound (US), scored as PU, were employed to detect finger DT. US was performed at the level of the dorsum of the middle phalanx of the third finger on both right and left hand, and the average value of DT was recorded in millimetres. mRss was calculated at the level of the dorsum of the fingers bilaterally, as reported in the literature (6). Statistical analysis was carried out by non parametric tests. Results SSc patients showed a statistically significant higher ultrasound-DT than healthy subjects, at the level of the fingers (p<0.0001). Ultrasound-DT was found progressively higher in SSc patients with the “early”, “active” and “late” NVC patterns of microangiopathy (p=0.05). Furthermore, there was a statistically significant positive correlation between ultrasound-DT and MES (r=0.29, p=0.03). A positive correlation was also found between mRss and MES (r=0.57, p<0.0001), as well as mRss was found progressively higher in patients with “early”, “active” and “late” pattern of microangiopathy (p<0.0001). A statistically significant positive correlation was observed between left and right finger ultrasound-DT (r=0.88, p<0.0001), as well as between ultrasound-DT and mRss (r=0.43, p=0.001). SSc patients with dcSSc showed higher mean values of ultrasound-DT than those with lcSSc (p=0.04). Furthermore, patients with dcSSc showed higher mRss and MES value than patients with lcSSc (p=0.0005 and p=0.004, respectively). Intra-operator variability in assessing DT by high frequency ultrasound technique was 6%. Conclusions This study describes and scores for the first time the correlation existing between progressive impairement of microvasculature and amount of dermal tickness in SSc patients. References Sulli A et al Arthritis Rheum. 2012; 64: 821-5. Moore TL et al. Rheumatology 2003; 42: 1559-63. Kaloudi O et al. Ann Rheum Dis. 2010; 69:1140-3. Sulli A et al. Ann Rheum Dis 2008; 67:885-7. Smith V et al. Ann Rheum Dis 2010; 69:1092-6. Clements PJ et al. J Rheumatol 1993; 20: 1892-6. Disclosure of Interest None Declared

Background Raynaud’s phenomenon (RP) is classified as primary (PRP) or secondary (SRP) depending on its association with an underlying disease. PRP can evolve to SRP when associated to connective tissue diseases, in particular systemic sclerosis, therefore a constant monitoring is necessary in these patients (1-2). Objectives This is a capillaroscopy-based prospective study to investigate the transition from PRP to SRP in a large cohort of patients, as well as to assess the appearance of the nailfold scleroderma-pattern of microangiopathy in patients with isolated RP, negative capillaroscopy and positive antinuclear antibodies (ANA) at baseline. Methods 2853 patients with RP were investigated by clinical interview, laboratory examinations, and nailfold videocapillaroscopy (NVC). Patients achieving a diagnosis of PRP at first visit (normal nailfold capillaroscopy, normal or negative laboratory findings, symmetric disease, absence of tissue ulceration, exclusion of an underlying disease) were yearly followed to monitor the appearance of specific morphological alterations at NVC, autoantibodies positivity, or clinical manifestations of an underlying disease. Nailfold microangiopathy was detected by NVC, and capillary abnormalities were scored and classified in the proper patterns of microangiopathy (“early”, “active” and “late“) (3-5). Results At first visit, 797 (28%) patients out of 2853 were showing a scleroderma-pattern by NVC and a diagnosis of SRP was obtained. Among the other 2056 patients showing a normal capillaroscopy at baseline, 1718 patients were lost during follow-up or not prospectively evaluable, and 338 patients were followed for a mean time of 50±39SD months. Among these last, 160 patients (47%) were positive for ANA, and 178 (53%) were ANA negative (PRP patients). During the follow-up, the scleroderma-pattern was diagnosed by NVC in 64 (19%) patients out of 338; in particular, it was found in 49 (31%) of the ANA-positive patients (28 “early”, 5 “active”, 9 “late”, 7 like-pattern at the end of the follow-up), and in 15 (8%) of the ANA-negative patients (14 “early”, 1 “active” NVC pattern at the end of the follow-up). The time of transition from normal/not specific capillary alterations to the “early” scleroderma-pattern was 3.5±3SD years. Enlarged capillaries (mean diameter 33 micrometres, range 21-50) and mild reduction of capillary density (observed number ≥8 capillaries/mm) were found the most frequent markers at first NVC visit in those RP patients who progressed to a scleroderma pattern. Conclusions This study demonstrates in a large cohort, that 8% of patients initially diagnosed as affected by PRP may transit to SRP. The transition from normal NVC pattern to scleroderma-pattern was observed in 19% of patients with RP, being more frequent in those with ANA positivity (31%). PRP patients showing major not-specific alterations of nailfold capillaries at first NVC, should be monitored every 6-12 months since at risk of transition to SRP. References Cutolo M, et al. Arthritis Rheum 2007;56:...