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Background:Although the management of rheumatoid arthritis (RA) has been booming since the advent of biological treatments, the consequences of this disease remain multiple, both physical and psychological.Objectives:The aim of our work was to investigate the factors influencing anxiety and depression in RA.Methods:This was a cross-sectional study of 49 RA patients. We used the Hospital Anxiety and Depression scale (HAD) to assess anxiety disorders.Results:We included 24 women and 5 men with an average age of 54.1 years. Sixty-nine percent of patients were unemployed and 81% had health insurance coverage. RA had been evolving for an average of 11.43 ± 7.32 years and the mean time to diagnosis was 2.35 years. It was erosive in 93.8% of cases. An atlanto-axial dislocation was found in 4.1% of cases and coxitis in 8.2% of cases. Eighty-three percent of patients were on cs-DMARDs and 14.2% were on biotherapy. Most patients had low active disease (53%) with a mean DAS28CRP score of 2.74 ± 0.81. Twelve percent of patients had a probable anxiety and 18% had a probable depression.A long delay in diagnosis was associated with a higher risk of anxiety disorders. Working patients had a lower risk of depression while patients from rural areas had a higher risk. The risk of anxiety and depression disorders was associated with increased VAS pain, EGP, and DAS28. In the multivariate study, EGP was the independent risk factor for the development of anxiety and depression disorders.Conclusion:Anxiety and depression disorders are a frequent yet underestimated consequence in RA. Appropriate care in psychiatry is required as soon as the diagnosis is announced.Disclosure of Interests:None declared

Background:In rheumatoid arthritis (RA), the ‘treat-to-target’ therapeutic approach imposes rigorous control of disease activity. Although biological agents have been shown to be effective, these therapies fail sometimes to achieve therapeutic goals.Objectives:In this study we tried to determine predictive factors of good therapeutic response to biologic disease-modifying antirheumatic drugs (bDMARD).Methods:This is a retrospective study including 374 Tunisian patients who received their first biotherapy between 2014 and 2016. Categorical variables were reported in numbers and percentages, while quantitative variables were expressed by mean with standard deviations. The univariate analysis was performed using the student t-test or the Chi2 test. Multivariate analysis was performed by binary logistic regression.Results:Average age of our cohort was 55 ± 12.5 years with a female predominance of 87.2%. The average duration of RA was 11.7 ± 6.7 years. Rheumatoid factors were positive in 79% and ACPA were positive in 72% of cases. After the introduction of biotherapy, low disease activity (LDA) or remission was achieved in 55% of cases (206 patients).No statistically significant difference between biotherapy responder and non-responder groups for age (55.7 vs. 54.7 years; p = 0.44), gender (Female: 86.5% vs. 88.7%; p = 0.08) and disease duration (12 years vs. 11.4 years; p = 0.41). A significant difference between the two groups was found for the positivity of rheumatoid factors (76.4% vs. 88.9%; p = 0.004), methotrexate’s association (65% vs. 53.4%; p = 0.02) and corticosteroids’ use (50% vs. 66.5%; p < 0.001).Positive predictive factors of remission or LDA by biotherapy were female sex (Odds Ratio = 2.2; p = 0.026), presence of rheumatoid factors (Odds Ratio = 2.64; p = 0.001), association with methotrexate (Odds Ratio = 1.69; p = 0.028). Whereas, corticosteroid use (OR = 0.41; p < 10-3) was a negative predictor of disease control by bDMARDs.Conclusion:Achieving LDA low level or even remission is currently achievable with biological treatments. Certain factors need to be studied in order to optimize RA treatment and adapt the right bDMARD for each patient.Disclosure of Interests:None declared

Background:Consequences of rheumatoid arthritis (RA) are many and varied: physical, psycho-affective and financial.Objectives:The objective of our study is to evaluate the impact of RA on sleep quality.Methods:We conducted a cross-sectional study including 49 RA patients. An evaluation of sleep quality using the MOS-Sleep Scale was performed.Results:The mean age of patients was 54.1 years, with a female predominance (89.8%). The mean duration of RA was 11.43 ± 7.32 years with a mean time to diagnosis of 2.35 years. Rheumatoid factor was positive in 77.6% of cases. A atlanto-axial dislocation was found in 4.1% of cases and coxitis in 8.2% of cases. All patients were on symptomatic treatment, 57.1% of whom were on corticosteroid therapy. 83.67% of patients were on cs-DMARDs and 14.2% were on biologics. At inclusion, sleep was optimal in 63.2% of cases and the mean Sleep Problem Index was 26.19 ± 22.77.The index of sleep problems was higher in older subjects and in those with long diagnostic delays. The presence of co-morbidities and atlanto-axial dislocation and/or coxitis was associated with impaired sleep quality. Also, VAS pain and EGP were associated with an increase in the sleep problem index. In the multivariate study, EGP, the presence of co-morbidities and atlanto-axial dislocation and/or coxitis were the independent factors affecting sleep quality.Conclusion:The impact of RA on the patient’s quality of life and especially the quality of sleep is confirmed by several studies in the literature. A global management of the patient is necessary in order to adapt well to his disease.Disclosure of Interests:None declared

Background:The development of biologic disease modifying antirheumatic drugs (bDMARD) has dramatically improved the management of rheumatoid arthritis (RA). However, some patients did not respond or partially respond to biologic agents. Management of first bDMARD failure may involve another biotherapy.Objectives:The aim of our study is to assess the efficacy of second line biologic as well as survival rates of 2nd line biotherapy in RA.Methods:This is a retrospective study based on Tunisian data including 374 RA patients treated with biologic agent from 2014 and followed until December 2018.Results:Tumor necrosis factor inhibitor (TNFi) was the most prescribed class as first-line therapy with 86.4% patients (Etanercept: ETA 54%; adalimumab: ADA 13.6%; certolizumab pegol: CZP 12.8% and infliximab: IFX 5.9%), IL-6 inhibitor (Tociluzimab: TCZ) and anti-CD 20 (Rituximab: RTX) were given respectively to 6.4% and 7.2% cases. The first biotherapy was discontinued for 146 patients (39%). Of these, 79 patients (21.1%) received a second bDMARD (mean age 52.6 ± 11.8; sex ratio = 0.12; ETA 17.7%, ADA 7.6%, CZP 41.8%, IFX 1.3%, TCZ 24.1% and RTX 7.6%). Average DAS28 at second line biotherapy initiation was 5.93 ± 0.96. Overall survival rates of 2nd line bDMARD at 12, 24 and 36 months was respectively 91%, 76.4% and 72.1%. Among the patients receiving second biologic agent, 30.4% patients (24 cases) achieved either low disease activity (LDA) or remission. On average 38 weeks [14 – 96] were needed to reach that therapeutic target. In fact, 27.8% of the TNFi vs. 40% of the non TNFi patients achieved LDA (p = 0.277). Second biotherapy was withdrawn in 16.7% of the cases of TNFi group vs. 20% of the non TNFi group (p = 0.718). Moreover, no significant difference has emerged between the TNFi and the non-TNFi patients when comparing time to biotherapy discontinuation (15.8 months vs. 20.9; p = 0.11).Conclusion:In our study, no significant difference was found between TNFi and non-TNFi switcher in RA. But, treatment strategy after first bDMARD failure is still controversial. Further studies have to be done to get the most beneficial strategy in RA.Disclosure of Interests:None declared

Background:Bone metastases (OM) or secondary cancers bones are bony locations of tumor cells, away from a primary malignant tumor. The Bone metastases are the most common metastases. They can be revealing in 20 to 30% cases or complicate the course of a known cancer. The bone metastases are a pejorative prognostic factor.Objectives:The aim of this study was to identify the Contribution of diagnostic methods for the quest of primitive cancer in presence of bone metastasis.Methods:We conduct a retrospective study of 35 files of patients who were hospitalized in the rheumatology department. All patients underwent a questionnaire and a clinical examination. Additional radiological assessment, bone biopsies, biopsies of other sites, bone scintigraphy and tumor markers were carried out on a case-by-case basis.Results:Thirty-five cases (25 men and 10 women) were analysed. The average age was 61 years [45-85]. Seven patients had a known history of neoplasia. One or more bone biopsies were performed in 8 cases. The vertebrae were the most biopsied bone site (6 cases). The bone biopsies were in favour of carcinoma (3 cases), adenocarcinoma (2 cases), squamous cell carcinoma (1 case) and inconclusive (2 cases). Non bony biopsies (2 pulmonary, 2 prostatic, 1 mammary) concluded to an adenocarcinoma (3 cases) and a carcinoma (2 cases). Bone scintigraphy was carried out in 7 cases and showed in all cases diffuse or localized hyperfixation. The localized value of tumor markers appeared relatively low except for Prostate Specific Antigen (PSA). Other metastatic localisations were identified: hepatic (6 cases) and pulmonary (1 case). The primary cancer identified was pulmonary for 11 patients, prostatic for 7, gynaecological for 4 and digestive for 3. One patient had Otorhinolaryngological cancer and another had bone cancer. Bone biopsy allowed the diagnosis in 6 cases (17%). The primary cancer was discovered by a biopsy of other non-bone sites in 5 cases (14%). Neoplastic antecedents and clinical context were considered sufficient in 16 cases (45%). Primary cancer remained undetermined in 8 cases (22%).Conclusion:Bone biopsy, as well as non-bone biopsy, remains an essential tool in the etiological diagnosis of bone metastases. They are very contributive in the same proportions. PSA is a major diagnostic asset in the search for primary cancer.Disclosure of Interests:None declared

Background:Tuberculosis is still endemic all over the world. The incidence of tuberculous spondylodiscitis (TS) is steadily increasing. Clinical features and outcomes of this affection are various and depending on various parameters, including age.Objectives:Our objective was to explore the differences in presentation and the results of further investigations and the prognosis of TS between young and elderly subjects.Methods:We conduct a retrospective and descriptive study in a single rheumatology department. Data were collected from files of patients hospitalized in the past 20 years (2000-2020) who have been diagnosed with TS. We carried out a comparative study concerning the clinical biological, imaging features and outcomes between young subjects and subjects aged over 65 years.Results:Fifty-two cases of TS were collected (37F/15M). The mean age of the population was 55.21 years ± 17.79 [19-91]. Thirty-three patients (69.2%) were classified as young versus 16 elderly patients (30.8%), with female predominance in both groups (69.4% and 75% respectively, p = 0.57). Young subjects was more frequently vaccinated (88.9%) by Bacillus Calmette–Guérin (BCG) (p < 0.001). A delayed diagnosis was noted in both groups (p = 0.24). Lumbar spine involvement was the most common (57.7%). In the two age ranges, the onset of the disease was progressive (p = 0.22), characterized by segmental spine stiffness (p = 0.57) and lumbar pain with general signs (p = 0.27), such as: impaired general condition, fever, night sweats and weight loss. Biological inflammatory syndrome and normochrome normocytic anemia were encountered in both cases (p = 0.08 and p = 0.2, respectively). Standard X-rays and Computed tomography were more performed in young subjects (94.4% and 69.4%, respectively; p < 0.001), unlike magnetic resonance imaging which was more common in elderly subjects but with no statistically significant difference (p = 0.22). Disc pinch, erosion of vertebral plateaus and vertebral collapse were the major signs (82.7%, 65.4% and 67.3%, respectively). Clinical, biological and imaging arguments contributed to positive diagnosis in both groups (p = 0.24). Common medical treatment was anti-tuberculosis: Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E) and physical treatment such as immobilization witch was more common in the eldery (56.3%, p = 0.16). The evolution of the disease was characterized by a clear improvement of young subjects during the second week of treatment (p < 0.001). A more frequent clinical improvement in older subjects was during the fourth week but with no statistically significant difference (p = 0.13). The occurrence of immediate complications was more frequent in the elderly (p = 0.23) with a predominance for drug complications (56.3%) such as: hepatic cytolysis (12.5%), hyperuricemia (18.8%) and major intolerance to anti-tuberculosis (18.8%).Conclusion:TS is a frequent condition that needs to be treated rapidly. the clinical presentation of TS in the elderly is less noisy which leads to more frequent complications and mortality.Disclosure of Interests:None declared

Background:Tuberculosis (TB) is no longer a disease limited to developing nations and is still a major cause of significant morbidity and mortality worldwide. It can affect the different parts of the spine.Objectives:The aim of this study was to determine the preferred spinal location of TB.Methods:We conduct a retrospective and descriptive study in a single rheumatology department. Data were collected from observations of patients hospitalized in the past 20 years (2000-2020) who have been diagnosed with tuberculous spondylodiscitis (TS).Results:Fifty-two patients were included (37F/15M). Their mean age was 55.21 years ± 17.79 [19-91]. TS was more frequently unifocal (75%) than multifocal (25%). Lumbar spine involvement was the most common (57.7%) and more frequent in women (63.3%) but with no statistically significant difference (p = 0.2). Other localizations were described such as: dorso-lumbar (21.2%), dorsal (15.4%), lumbosacral (3.8%) and cervical (1.9%). Lumbar pain was present in 34 patients (65.4%) and 29 patients (55.8%) suffered from segmental lumbar stiffness. Imaging was contributive by showing the vertebral location using standard X-rays, computed tomography and magnetic resonance imaging. Disc pinch, erosion of vertebral plateaus and vertebral collapse were the major signs (82.7%, 65.4% and 67.3%, respectively).Conclusion:TS is a rare but serious clinical condition which may lead to severe deformity and early or late neurological complications. Spinal involvement is often unifocal and mostly diagnosed with lumbar pain or stiffness. Multifocal forms, touching several parts of the spine, however remain rare. Our findings remain consistent with those of the literature.Disclosure of Interests:None declared

Background:Low back pain (LBP) is a common health problem among all age groups. Medical students do not seem to be spared. In fact LBP is one of the most common musculoskeletal disorder and its prevalence is variable ranging from 41% to 72%.Objectives:The aim of our study was to determine the prevalence of LBP among Tunisian medical students and to assess its associated factors.Methods:We conducted a cross-sectional study over 2 months carried out on medical students in a Tunisian medical college. A digital questionnaire entered by Google forms was sent by e-mail and was completed by the students. Our study included students from the first year of the first cycle of medical studies up to the third year of the second cycle. Socio-demographic, personal characteristics and life habits were collected. LBP was assessed using the Nordic musculoskeletal health questionnaire. The impact of low back pain was assessed using the Oswestry disability index (ODI).Results:One hundred and seventy-nine students were included. The mean age was 22.9 ± 2.3 years [19.64-38.21]. The sex ratio was 0.29. The average body mass index was 23.55 ± 4.22 kg / m2 [17.67-43.07]. 82% of the students were in the second cycle of medical studies. 26.4% of the students had a regular sports activity. 91.2% spent more than 4 hours a day in a sitting position. The point, annual, and lifetime prevalence of LBP among medical students was 41.2%, 80.4% and 90.6%, respectively. Low back pain was acute in more than 58.8%, subacute in 14.9% and chronic in 26.3%. The mean ODI score was 10.32% ± 8.48% [0-32%]. Students with LBP were significantly younger than students without LBP (p = 0.015). LBP was more common in students who spent more than 4 hours in a sitting position with a difference at the limit of significance (p = 0.059). Being in the 2nd cycle was significantly associated with the occurrence of LBP (p = 0.006). Poor screen projection in the amphitheater was significantly associated with the occurrence of LBP (p = 0.029).We found a statistically very significant relationship between the occurrence of LBP and the poor layout of the amphitheaters (p = 0.000). The feeling of depression was significantly higher among LBP students (p = 0.018). Feelings of fatigue, being overwhelmed, irritability and worry were more frequently found in LBP students, but this difference was not statistically significant. In a multivariate analysis, the only factors that remained statistically significant were feeling of depression (p = 0.046, OR = 3.88; CI = [1,3-11,55]) and the poor layout of the amphitheaters (p = 0.006, OR = 8.99; CI = [2.55-31.69]).Conclusion:The annual prevalence of LBP was 80.4%. These results testify to the magnitude of this health problem. The factors associated to LBP seemed to be essentially modifiable factors. This encourages special attention from medical schools to increase students’ awareness of low back pain and to provide appropriate measures at reduce this musculoskeletal disorder.Disclosure of Interests:None declared

Background:The advent of biotherapies in the late 90s radically changed the face of inflammatory diseases including rheumatoid arthritis. The survival of these innovative therapies is an indicator, in clinical practice, of their long-term efficacy and safety.Objectives:The objective of this study was to assess their use in Tunisia through their survival during rheumatoid arthritis as well as to determine the factors that may influence their therapeutic maintenance in real life.Methods:This is a retrospective study including RA patients (ACR/EULAR 2010 criteria) and putted on biotherapy between 01-01-2014 and 12-31-2016. They were followed until 12-31-2018. The therapeutic maintenance rate at 12, 24, 36 and 48 months as well as the survival curves of biotherapies were analyzed using the Kaplan-Meier survival curves and compared by the Log-rank test. Reasons for interruption and patterns of biological change have been reported. Finally, an analysis of factors influencing survival was performed using Cox regression.A pResults:Three hundred seventy-four patients were included in the study; sex ratio was 0,147. The baseline age was 55 ± 12.5 years [20 – 90] and the average disease duration was 11.7 ± 6.7 years [2 – 41]. Rheumatoid factor and ACPA were positive respectively in 79% and 71% cases. After failure of cDMARD, the first biotherapy prescribed was etanercept in 54% of cases, adalimumab in 14% of cases, certolizumab pegol 13%, infliximab 6%, tocilizumab 6% and rituximab in 7% of cases, with an average DAS28 at baseline 6.01 ± 0.89 [5,37 – 6,50]. Association with methotrexate was observed in 59,6% case and with corticosteroid in 57.2% case. Drug persistency rate at 12 months was 85.8%; at 24 months, 69.9%; at 36 months, 60.6% and at 48 months, 55.9%. Survival was on average 41.7 months with 95% CI (39.47 - 43.91). The presence of rheumatoid factors, the co-prescription of methotrexate as well as good initial therapeutic response were predictor of a better survival of biologicals at a statistically significant level pConclusion:Our study provides information about biotherapy prescription practices in Tunisia and their effectiveness in “real life”. It informs us about the use of these new therapies in our country and has shown an efficacy and a tolerance profile close to those reported in international registers.Disclosure of Interests:None declared

Background:Osseous hydatid cyst is an uncommon disease with weak response to treatment.hydatid disease should be included in the differential diagnosis of cystic lesions of bone in endemic regions. Bone cysts account for only 0.5 to 2.5% of all hydatid cysts in humans.Objectives:To report a case of osseous hydatid disease extended on hip and femurMethods:We report a case of osseous hydatid diseaseResults:A 49 YEAR OLD BRICKLAYER, with no past-medical history and no animal contact, was admitted to our department for a left hip pain. the patient was apyretic and in a good general health condition. He had a very painful walk. the mobilility of the left hip joint was very painful and restricted.The pelvis X-rays showed osteolytic lesions in the ischiopubic branch and in the left femur and proximal extremity of the tibia.The C-Reactive protein value, the protein electrophoresis were normal. tumor markers test was negative.An ultrasound of the hip showed a low abondance intra-articular effusion. The Pelvic MRI showed multilocular appearance extending over the bone and muscle with breach of the bone cortex of the femur very suggesting of the diagnosis of a bony and muscular echinococcosis.NO other localization of hydatidosis were detected, body ct scan was normalConclusion:Hydatid disease occurs worldwide and mainly associated with sheep farming. The liver and lungs are the most common locations. Bone cysts are uncommon but severe. Although immunofluorescent assays are useful, the final diagnosis depends on histology. The treatment is almost surgery. Recurrence is commonDisclosure of Interests:None declared

Background:During the last decade, the treatment of chronic inflammatory rheumatism (CIR) has been greatly improved with the advent of biotherapy.However, the use of biological treatment can lead to a number of side effects including abnormalities in the blood count.Objectives:The aim of this study was to assess the different hematological side effects of biological treatment in patients with rheumatoid arthritis (RA) and spondyloarthitis (SA).Methods:This study included patients with RA (ACR/EULAR 2010) and SA (ASAS 2009) registred with the Tunisian Biologic National Registry (BINAR).Patients were followed and treated with biologics for 2 years of less. Clinical data relative to biological treatment, including haematological side effects, have been collected.Results:Two hundred and ninety-eight patients (178 women and 111 men) were included in the study.The mean age was 49.2 ± 14.1 years. The male/female ratio was 0.6. The mean diseases durations for RA and SA were respectively 6.7 ± 3.5 years and 6.5 ±3.6 years.Anti-TNFα agents were prescribed in 87.9% of patients (n = 263) with respectively: Infliximab (20.4%) Etanercept (23.1%), Adalimumab (24.6%) and Certolizumab (26.5%).Tocilizumab and Rituximab were prescribed in 10.4% and 5% of the patients, respectively.Blood count abnormalities were noted in 15.4 % of patients (n=46).Neutropenia was the most frequently anomaly met on the hemogram (9.1%) followed by anemia (3.4%) and thrombocytopenia (3%). Pancytopenia was found in 11.4% of patients (n=34).The median time between biological therapy initiation and the onset of hematologic manifestations was 4.8 months [1-12]. Biological treatment was interrupted in two patients.In the other cases, the biological treatment was maintained with close monitoring of blood cell count. No case of death related to these hematological disturbances has been reported.Conclusion:In our registry, hematological side effects of biological treatment were found in 15.4% of cases and were noted with a median delay of 4.8 [1-12] months after the treatment initiation. Further studies are needed to confirm our preliminary results.Disclosure of Interests:None declared

Background Brucellosis is a major health problem in Mediterranean countries, including Tunisia. The clinical presentation of this zoonosis varies considerably, but osteoarticular involvement and spinal brucellosis particularly, is the commonest complication. Methods This study was carried out between 2006 and 2013. Forty patients with infectious spondylodiscitis hospitalized in the department of Rheumatology were analyzed. All patients were thoroughly interrogated, subjected to a rigorous clinical examination and a battery of investigations including: complete blood count, urine analysis, blood culture, erythrocyte sedimentation rate, C-reactive protein (CRP) and serology for brucellosis. The imaging ordered including: plain X-ray of the lumbosacral spine, bone scan and magnetic resonance imaging (MRI) with contrast enhancement of the spine. Results Ten of the forty patients (25%) proved to have spinal brucellosis. The mean age of this patients was 51 years (range 15 – 68 years) and female/male ratio: 1,5. The mean delay of diagnosis was 7 months. The following symptoms were observed: fever in 9 patients and back pain in all patients. Other symptoms were less frequently observed, such as splenomegaly (one patient), peripheral adenopathy (two patients) and diarrhoea (one patient). Laboratory exams showed elevated erythrocyte sedimentation rate in most of them (8 patients), high levels of CRP in all patients and leukocytosis in 7 cases. Wright serology was positive in all of them. Brucella melitensis was isolated in blood cultures in 2 cases. Standard X-rays were performed in all patients; they showed signs of spondylodiscitis in the lumbar spine in 5 cases, cervical in one case and dorsal in two cases. CT-scan and MRI confirms the diagnosis and showed associated epiduritis (3cases) or abscess (4 cases). Bone biopsy and histopathological examination were performed in three cases. A combination of cycline and rifampicin was given to all patients. The duration of therapy was between 6 and 8 weeks. Conclusions Brucellosis is present with various clinical signs in endemic areas and may simulate many diseases. The need for prompt diagnosis and treatment of spinal brucellosis is of the utmost importance to prevent serious bone destruction and severe neurologic sequelae. Disclosure of Interest None declared

Background Enthesitis is the inflammatory process marked by the insertions of tendons, ligaments and joint capsules on the bone and it is the cardinal feature and diagnostic criteria of spondyloarthritis (SpA). Although, it is usually revealed by clinical examination, the enthesitis can be asymptomatic, both in the axial and peripheral skeleta. Objectives Our objective is to investigate by colour Doppler ultrasound (CDU) the modality and the frequency of involvement of Achilles enthesitis, the main site of involvement in SpA after calcaneal entheses, to identify its characteristic features, and to correlate these findings with clinical complaints and radiographic evidence. Methods Our study is prospective. Thirty patients with SpA diagnosis were included. The diagnoses were ankylosing spondylitis in 18 patients, psoriatic arthritis in 8, SpA associated with inflammatory bowel diseases (IBD) in 3, and Reiter9s disease in one patient. All of them were clinically evaluated and underwent CDU examination of Achilles entheses. Particular attention was given to the detection of enthesis thickness, structure, cortical bone insertion, junction between tendon and entheses, body of tendon, calcifications, erosions, bursae, power Doppler signal and vascularization. Results Patients male/female ratio was 4 (24/6), mean age was 30 (range 16-53) years and mean disease duration was 8 (range 1-13)years. Mean (SD) BASDAI and BASFI scores were 33 and 64 respectively. Twenty-three of the 30 SpA patients (76%) showed at least one abnormal finding of the enthesitis on CDU examination, affecting 43 of 60 Achilles entheses examined (71%). Only 11 Achilles entheses (18%) showed vascular signals in the periosteal areas or in the area of enthesis fibrocartilage. Ultimate correlations were found between pain and tenderness with increased vascularity. In addition, 29 (48%) and 8 (14%) of 60 Achilles entheses examined showed, respectively, cortical bone irregularities and erosions. Fourteen (87%) of 16 clinically detected Achilles enthesitis and 4 (57%) of 7 Achilles entheses with swelling on clinical examination presented corresponding abnormalities on CDU examination. CDU revealed Achilles tendon calcifications in 30% without significant correlation between talalgia or sex of patients but with excellent agreement with radiography. Deep retrocalcaneal bursitis was found in 3 (13%) and there was a significantly correlation with talalgia. Conclusions This study demonstrates the characteristic features of Achilles enthesitis detectable by CDU in the SpA and shows a good correlation with clinical as well as with radiography findings. It may be useful and complementary to the clinical evaluation to track down this reach of Achilles tendon. Further researches are needed to improve the role of CDU in diagnosis and follow up of SpA course. References Li CA, Kim HO, Lee SY, Lee SI. Assessment of Achilles enthesitis in the spondyloarthropathies by colour Doppler energy ultrasound in the context of the “enthesis organ”. Scand J Rheumatol. 2010 Mar;39(2):141-7. Disclosure of Interest None declared

Background Interstitial lung disease (ILD) is a common extra-articular manifestation of rheumatoid arthritis (RA) and a significant cause of morbidity and mortality. Objectives The objective of this study was to define high-resolution chest CT (HRCT) and pulmonary function test (PFT) abnormalities to identify asymptomatic, preclinical forms of RA-ILD that may represent precursors to more severe fibrotic lung disease. Methods Our study is prospective. We collect 20 RA patients with no respiratory functional sign. All patients met the 1987 diagnostic criteria of the American College of Rheumatology (ACR). We analyzed chest HRCTs in consecutively enrolled RA patients and subsequently classified these individuals as RA-ILD or RA-no ILD based on the presence/absence of ground glass opacification, septal thickening, reticulation, traction bronchiectasis, and/or honeycombing. Coexisting PFT abnormalities (reductions in percent predicted FEV1, FVC) were also used to further characterize occult respiratory defects. Results Twenty patients were included in the study. Their demographic and clinical characteristics are summerized in the table below. In this study, all RA patients were treated with combinations of DMARDs and cortico steroids (7.5 mg per day) that included methotrexate (MTX), with a dose ranging from 10 to 15 mg (mean at 12.33 mg) per week; however, only 4.6% of RA patients used Leflunomide (20 mg per day). In terms of additional environmental risk factors, the prevalence of smoking was very low (1/20). Radiographic abnormalities are objectified in 4 cases 20% of cases. The most common abnormality is represented by interstitial syndrome found in 3 cases: diffuse reticulomicronodular images in 2 cases and pleural thickening in one case. The results of our study showed a restrictive syndrome in 5 cases (25%) and a mixed syndrome in 1 case (5%). Among the 13 patients with ILD on HRCT, only 4 have a restrictive syndrome. As regards the restrictive syndrome (CVF equal to 69% of the theoretical in both cases), corresponding HRCT was normal. In the case of mixed syndrome CT revealed centrolobular and para septal emphysema predominantly in the bi upper lobe. Conclusions HRCT represents an effective tool to detect occult/asymptomatic ILD that is highly prevalent in our unselected, university-based cohort of RA patients. Disclosure of Interest None declared

Background Fibroblast growth factor-23 (FGF23) is a bone-derived hormone. The association between FGF-23 levels and clinical outcome in hemodialysis patients suggests that FGF-23 can be considered as a cardiovascular risk in this population, Moreover, relationship between FGF-23 and osteoporosis remains unclear in dialysis patients. Objectives The aim of the study was to demonstrate the association between FGF-23 levels with either osteoporosis and cardiovascular risk factors in hemodialysis patients. Methods We conducted a transversal study over a period of 4 years [2009-2012] including 80 patients under hemodialysis therapy over one year period. Blood samples were drawn before hemodialysis session from patients. We measured calcium, phosphate, 25 OH-vitamin D and fibroblast growth factor (FGF23). Bone mass density (BMD) was measured by dual energy X-ray absorptiometry (DXA) at the lumbar spine and total hip. Lumbar spine X-rays were used to diagnose vascular calcification. All statistical analysis were performed using the Windows SPSS 19 package. Results Eighty patients were included: 51 male and 29 female. The mean age was 53.27 years [20; 89]. The mean age of onset of hemodialysis was 50.42±14.49 years. The mean body mass index (BMI) was 25.91±4.86 kg/m 2 and the mean weight was 68.16±13.36 kg. Diabetes, hypertension and dyslipidemia were observed respectively in 45%, 66.3% and 15% of cases. Serum calcium and phosphorus levels were respectively 2.06±0.39 mmol/L and 1.83±0.57 mmol/L. The average rates of parathyroid hormone (PTH), vitamin D and FGF23 were respectively 422.60±382.8 pg/mL 15.92±11.39 ng/mL, and 248.96±221.87 pg/mL. Osteoporosis affected the hip in 20% of cases and the spine in 9% whereas osteopenia was observed in 44% of cases in the hip and 33% of cases in the spine lumbar. Vascular calcifications (CV) were found in 31.11% of cases. Negative correlation was observed between FGF23 and vitamin D (r: -0.245, p: 0.027). Patients with dyslipidemia had higher FGF23 levels than patients without dyslipidemia (239.28 pg/mL vs 123.19pg/mL). No correlation was found between FGF23 and following parameters: calcium and phosphorus levels, PTH levels, BMI and weight. FGF levels 23 tend to be higher in hemodialysis with CV but this difference was not significant (275.85 pg/mL vs 195.88 pg/mL, p:0.231). Lumbar osteoporosis was associated with high concentrations of FGF23. Conclusions Our study showed that FGF-23 levels are increased in hemodialysis patients. We demonstrate also that higher concentrations of FGF23 are associated with osteoporosis in lumbar spine. Given the association FGF23 and dyslipidemia, this factor can be considered as a cardiovascular risk in hemodialysis patients. Disclosure of Interest None declared

Background Spondyloepiphyseal dysplasia (DSE) is a genetic chondrodysplasia causing early osteoarthritis witch predominates in hips, knees and shoulders. We report in this context 7cases. Objectives We propose to study the clinical and radiologcal features of spondyloepiphyseal dysplasia in our patients. Methods We studied the clinical and radiological features collected from records of patients treated for spondyloepiphyseal dysplasia. Results This was 7 patients (4H/3F) 31. Their middle age was 31,5 years. The diagnosis delay was on average 6,25ans [4 months-13 years]. Clinical signs were present in all cases: low back pain in 3 cases, hip disease in 3 cases, and a dwarfism in 2 cases. The clinical examination objectified abnormalities in all patients. This was strain in six cases: flexion of the elbows and/or knees, scoliosis in 3 cases each. Joint restriction in one or both hips was observed in 2 patients. The diagnosis was retained in all patients on radiological data. Vertebral dysplasia was demonstrated in 4cas. Femoral involvement was noted in 2 cases (pseudo rheumatoid dysplasia), knees in 2 cases. Three patients underwent measurement of bone mineral density, which found osteoporosis. Treatment was to prescribe analgesics and nonsteroidal antiinflammatory for all patients, a support unit in rehabilitation and physical medicine in one case and total hip in one case. Conclusions SDE is a child or adolescent pathology which must always be suspected in advanced osteoarthritis in young adults. Early diagnosis, through a better understanding of this entity, could improve the quality of life of these patients. References Kohler G, Hesse B. Epiphyseal dysplasia–symptoms and differential diagnostic aspects. Z Orthop Ihre Grenzgeb. 2004 Jul-Aug;142(4):397-402. Acknowledgements SDE. Disclosure of Interest None declared

Background Low bone mass is common in patients undergoing hemodialysis. Osteoporosis can be associated with serious bone health problems, especially fragility fractures. Objectives The aim of the study was to determine the frequency of osteoporosis in hemodialysis Tunisian patients and to identify the risk factors of low bone mass in this population. Methods We conducted a cross-sectional study over a period of 4 years [2009-2012] including 90 hemodialysis. Blood samples were drawn before hemodialysis session from patients. We measured calcium, phosphate, alkaline phosphatase (ALP) and intact parathyroid hormone (PTH). Bone mass density (BMD) was measured by dual energy X-ray absorptiometry (DXA) at the lumbar spine and total hip. Using WHO criteria as a cutoff point, osteopenia was defined as a T-score lower than -1 and osteoporosis was defined as a T-score lower than -2.5. All statistical analysis were performed using the Windows SPSS 19 package. Results Ninety patients were included: 58 male (64%) and 32 female (36%). The mean age was 53.01±14.60 years. The mean age of onset of hemodialysis was 50.06±14.82 years. Serum calcium and phosphorus levels were respectively at 2.084±0.32 mmol/L and 1.84±0.57 mmol/L. The average rates of PTH and ALP were respectively at 425.70±380.78 pg/mL and 88.35±72.56 UI/L. Fifty six percent of patients have PTH values between 2 and 9 times the upper normal limit of the assay as recommended by KDIGO (Kidney Disease: Improving Global Outcomes). However, 19% of patients have PTH values less than 2 times the upper normal limit of the assay. The mean of BMD was 0.854±0.152 g/cm 2 in the hip and 1.155±0.218 g/cm 2 in the lumbar spine. Twenty three percent of patients have osteoporosis and 45% have osteopenia. Osteoporosis affected the hip (20%) more than the spine (5.5%). Regarding risk factors, femoral BMD had significant negative correlations with the with the following parameters: age (r:-0.289; p:0.006), age of onset of hemodialysis (r:-0.359; p:0.001) and PTH level (r:-0.275; p:0.009). However, no correlations was found between lumbar spine BMD and the following parameters: age, age of onset of hemodialysis, calcium, phosphorus and PTH level. Conclusions Our study showed that osteoporosis is common in dialysis patient [1]. The most common region of bone loss was the hip. The decrease in cortical BMD was associated with advanced age, age of onset of hemodialysis and elevated levels of PTH [2]. References Nybo M, Jespersen B, Aarup M, Ejersted C, Hermann AP, Brixen K. Determinants of bone mineral density in patients on haemodialysis or peritoneal dialysis–across-sectional, longitudinal study. Biochem Med. 2013;23(3):342-50. Huang GS, Chu TS, Lou MF, Hwang SL, Yang RS. Factors associated with low bone mass in the hemodialysis patients–a cross-sectionalcorrelation study. BMC Musculoskelet Disord. 2009; 4;10:60. Disclosure of Interest None declared

Background This is the second part of the study about the prevalence of osteoporotic fractures in the Tunisian population and which includes 1311 women, aged 64.07±9.31 years, which revealed the presence of fractures in 212 women (16.2%), mainly represented by vertebral fractures (59.83%). What about the subsequent risk of fracture in this cohort? [1] Objectives The aim of this study was to determine the probability of fracture predicted by Frax (fracture risk assessment tool) comparing women with and without history of fracture. Methods A prospective and comparative cohort of 111 postmenopausal women with medical history of fracture (G1) and 111 postmenopausal women without medical history of fracture (G2), matched for age, race and body mass index were included in the study. BMD was measured by dual energy X-ray absorptiometry (DXA) at lumbar spine and femoral neck. We calculated Frax values for hip in both groups and evaluated osteoporotic fracture in this cohort. Both statistical and descriptive analyses were performed. Results The mean age was 65.92±9.48 years in G1 and 64.55±9.98 years in G2 (p=0.296). BMI values in G1 and G2 were respectively 29.18±4.96 and 28.82±4.62 kg/m2 (0.573). Mean values of FRAX TOOL for major osteoporotic fracture in G1 and G2 were respectively 1.507±0.788 and 0.764±0.390 (p=0.000). And, mean Frax values for hip fracture in G1 and G2 were 0.384±0.504 and 0.161±0.232 respectively (p=0.000). The discriminative capacity of FRAX analyzed by the Area Under Curve (AUC), Receiver Operating Characteristics (ROC). The AUC were 0.873 (CI 95%; 0.827-0.919) for major osteoporotic fracture and 0.68 (CI 95%; 0.612-0.752) for hip fracture. Therefore odds ratio for major osteoporotic and hip fracture were 18.2 and 3.1. ![Figure][1] Conclusions Our study confirmed the significant increase of fracture risk in patients with a history of fracture thereby enhancing the need to strengthen prevention of osteoporosis fracture in our population. Furthermore, our study demonstrated that in Tunisian female patients, cut-off FRAX values are 0.873 and 0.68 for major osteoporotic fracture and hip fracture respectively References 1. Sahli H, Testouri N, Chihaoui MB, Salah AH, Cheour E, Meddeb N, Zouari B, Sellami S. Bone mineral density in healthy Tunisian women. Maturitas. 2009 Jul 20;63(3):227-32 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5697 [1]: pending:yes

Background Although bone biopsy is a golden standard in the diagnosis of chronic kidney disease mineral and bone disorders (CKD-MBD), this method is invasive and repetitive evaluation of bone status cannot be possible. Objectives The aim of this study was to clarify the issue of bone metabolic markers in regular hemodialysis (HD) patients. Methods A prospective study included 90 patients under HD therapy over a three month period. Hematological and biochemical blood samples were collected after at least 10 h of fasting just prior to the HD session. One bone formation markers: bone-specific alkaline phosphatase (BAP) and one bone resorption marker carboxy-terminal telopeptides of type 1 collagen (CTx) were selected for study. Both statistical and descriptive analyses were performed. Results Ninety patients were included: 58 male (64%) and 32 female (36%). The mean age was 53.01±14.66. The body mass index was 25.79±4.67 kg/m 2 . The mean age of onset of nephropathy was 48.40±15.09. It was diabetic nephropathy in 30 cases, glomerulonephritis in 34 cases, vascular nephropathy in 6 cases, amyloidosis in 1 case, polycystic in 4 cases, tubulointerstitial nephropathy in 9 cases and indeterminate nephropathy in 6 cases. The mean age of onset of HD therapy was 50.06±14.82 years. The levels of BAP and CTx showed a strongly positive correlation (r=0.56, p Conclusions The determination of serum intact parathyroid hormone has been used for many years as an indirect predictor of CKD-MBD. The introduction of modern biomarkers of bone metabolism offers the possibility of a direct assessment of bone metabolism. BAP is a bone formation marker, it is not influenced by either renal dysfunction or the HD procedure because it is exclusive metabolized in the liver. Thus, serum BAP concentration can provide useful information about the rate of bone remodeling in HD patients. Even if CTX is cleared by the kidney, our study showed that circulating BAP and CTx levels are strongly correlated with serum PTH levels. Therefore, in HD patients, bone metabolic markers including BAP and CTx may accurately reflect bone turnover. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.6000