Search

Objective To determine the current state of Rheumatology in Catalonia and to update the information regarding previous studies. Material and methods Design Observational, descriptive and cross-sectional study. Data collection from January to June 2017. Sample Rheumatologists practising public healthcare activity in Catalonia. An online questionnaire was sent to gather individual data and data from rheumatology services/sections. Results Information was obtained on 109 rheumatologists: 39 men and 70 women; mean age: 47 ± 9 years. The number of rheumatologists has increased by 8% over the past 5 years. One hundred and one (92.7%) doctors qualified as rheumatologists through the MIR. Rheumatology practice was mostly in a hospital setting: 68 (62.4%) physicians. Ninety-six (88.1%) rheumatologists were full-time practitioners. Fifty-four (50%) rheumatologists also practiced in the private sector. Clinical practice was predominant: 76% of daily time was devoted to this area. Of note, it was found that most of the rheumatology services, 24 (705), were dependent hierarchically on other services, namely internal medicine and orthopaedic surgery. There are still 6 hospitals in Catalonia without a rheumatologist. Conclusions The number of rheumatologists in the public health sector of Catalonia has increased over the past 5 years. The mean age of rheumatologists is advanced and there is a clear predominance of female practitioners in the specialty. Many rheumatology services depend on other services. Rheumatology activity is primarily focussed in the city of Barcelona.

Elderly-onset rheumatoid arthritis (EORA) and polymyalgia rheumatica (PMR) are common rheumatic diseases in older adults. Oxylipins are bioactive lipids derived from omega-6 (n-6) and omega-3 (n-3) polyunsaturated fatty acids (PUFAs) that serve as activators or suppressors of systemic inflammation. We hypothesized that arthritis symptoms in older adults were related to oxylipin-related perturbations. Arthritis in older adults (ARTIEL) is an observational prospective cohort with 64 patients older than 60 years of age with newly diagnosed arthritis. Patients’ blood samples at baseline and 3 months posttreatment were compared with 18 controls. A thorough clinical examination was conducted. Serum oxylipins were determined by mass spectrometry. Data processing and statistical analysis were performed in R. Forty-four patients were diagnosed with EORA and 20 with PMR. At diagnosis, EORA patients had a mean DAS28CRP (Disease Activity Score 28 using C-reactive protein) of 5.77 (SD 1.02). One hundred percent of PMR patients reported shoulder pain and 90% reported pelvic pain. Several n-6- and n-3-derived oxylipin species were significantly different between controls and arthritis patients. The ratio of n-3/n-6 PUFA was significantly downregulated in EORA but not in PMR patients as compared to controls. The top two candidates as biomarkers for differentiating PMR from EORA were 4-HDoHE, a hydroxydocosahexaenoic acid, and 8,15-dihydroxy-eicosatrienoic acid (8,15-diHETE). The levels of n-3-derived anti-inflammatory species increased in EORA after treatment. These results suggest that certain oxylipins may be key effectors in arthrtis in older adults and that the imbalance between n-6- and n-3-derived oxylipins might be related to pathobiology in this population.

To study retention of biologic disease-modifying anti-rheumatic drugs (bDMARDs) or apremilast and potential predictors of lack of response in patients with psoriatic arthritis (PsA). A single-center retrospective analysis of PsA patients who received ≥ 1 bDMARD or apremilast during 2000–2018. The main endpoint was lack of response (primary or secondary failure). Analyses included retention of DMARDs (Kaplan–Meier curves) and potential predictors of lack of response (bivariate and multivariate logistic regression models). A total of 159 patients with PsA received up to 8 DMARDs: etanercept (34%), adalimumab (30%), infliximab (9%), golimumab (9%), apremilast (7%), ustekinumab (5%), certolizumab (4%), and secukinumab (2%). Therapy was discontinued in 96 cases (60%), mainly owing to secondary failure (37%), followed by primary failure (25%) and adverse effects (24%). Retention was analyzed based on 313 units of analysis. Duration of follow-up was 846.1 treatment-years (maximum 14.8 years, median 2.75 years). A total of 172 DMARDs were discontinued. The probability of continuing the initial treatment was 37% at 5 years, 22% at 10 years, and 12% at 14 years. The longest medium retention time was observed for infliximab (6.2 years) and etanercept (4.5 years). Predictors of lack of response included male sex, number of swollen joints, and, especially, depression (OR = 35.2). The sensitivity and specificity of the model were 86.4% and 85.7%, respectively, with a coefficient of determination (R2) of 45.6 (ROC, 0.912). Rates of discontinuation due to primary and secondary failure are high in PsA. Retention is better for anti-TNF agents than for other agents.

Objective Septic arthritis is a medical emergency and crystal-induced arthritis is a risk factor for its development. If both occur simultaneously, crystal-induced arthritis may mask the diagnosis of infection and delay antibiotic therapy. Method Retrospective analysis of patients with coexistence of septic and crystal-induced arthritis. We included only patients with isolation of crystals in synovial fluid analysis and positive culture of synovial fluid and/or blood culture. Results A total of 25 patients (17 men and 8 women) with a mean age of 67 years. The most commonly affected joint was the knee. In synovial fluid cytological studies, the most frequently identified crystals were monosodium urate. Risk factors included diabetes and chronic renal failure. The most frequently isolated germs were methicillin-sensitive Staphylococcus aureus (48%), methicillin-resistant S. aureus (12%) and Mycobacterium tuberculosis (12%). In all, 36% of subjects required surgical drainage (excluding those caused by M. tuberculosis). Clinical outcome was favourable in 56%, although intercurrent complications were usual (40%). Mortality was 8%. Conclusions Coexistence of septic and crystal-induced arthritis represents a diagnostic challenge and requires a high index of suspicion. Gout was the most prevalent crystal-induced arthritis. S. aureus was the most commonly causative pathogen, with a high rate of methicillin-resistant S. aureus infection. If treated early, the outcome is usually favourable, making synovial fluid microbiological study imperative.

Background Myositis specific antibodies have gained special importance in last years. Its knowledge has allowed stratifying patients in different clinical phenotypes, predicting with greater accuracy prognosis and establishing a clinical attitude to follow. SAE1/2 antibody (anti-small ubiquitin-like modifier activating enzyme) was first described in 2007 in patients with amyopathic dermatomyositis with cutaneous and digestive involvement. Its prevalence ranges from 8% in European cohorts to 3% in asians. Objectives Describing myositis specific antibodies (MSA) in a cohort of inflammatory myopathies. To characterize the clinical phenotype of SAE1/2 antibody and to compare it with the rest of MSA. Methods Patients diagnosed of dermatomyositis in a tertiary hospital from 1978-2018, according to the criteria of Bohan and Peter (1975) and according to Dalakas classification criteria (2015). Clinical and analytical data, including the immunological profile were collected, as well as the treatments received and the evolution of the disease. Results Out of 46, 41 dermatomyositis had positive antinuclear antibodies (ANA). 55% percent had aNA titles≥640, being the fine speckled pattern the most frequent (43%) followed by coarse speckled and homogeneous (13.6% each). 72% had MSA, the most frequent being antiJo1 (27.3%) followed by MDA5 (18.2%) and SAE1/2 (15%). Up to 40% had two or more antibodies, being the association with antibodies Ro52 and Ro60, the most frequent. 5 patients presented positivity against SAE antibody. In comparison to the rest of MSA, 80% presented with cutaneous debut (p = 0.00), being the most frequent manifestations heliotrope erythema (p = 0.00), Gottron papules (p = 0.10) and skin rash (p = 0.00). 60% had pathological capillaroscopy compared to 15% (p = 0.00). Muscular balance was preserved in 60% of patients. Sixty percent had dysphagia vs 9% (p = 0.00). Two of them had lung involvement (alveolar hemorrhage and rapidly progressive pneumonitis). In comparison with SAE negative group, patients presented more pulmonary hypertension (44.5vs34 mmHg), without reaching significant differences. No significant differences were found between muscle enzyme levels’ neither acute phase reactants. As complications, one patient presented a myocarditis with quickly rapidly progressive pneumonitis that required high doses of corticotherapy and another one alveolar hemorrhage, which was treated the same way. All patients required corticotherapy at doses of mg/kg, requiring two of them to be treated with DMARDs (methotrexate and dolquine) and one of them with immunoglobulins due to cutaneous involvement. Mortality rate was 40% due to rapidly progressive lung affectation and cardiorespiratory arrest. Conclusion Higher prevalence of SAE1/2 antibody in our cohort may be explained due to the use of amplified myositis antibodies kit that specifically includes this antibody. These patients typically present with cutaneous involvement and dysphagia but also lung affectation as a complication. Studies with larger samples should be performed in order to know the prognosis of this antibody specificity. Disclosure of interests None declared

Background: Rheumatoid arthritis (RA) patients have a higher insulin resistance (IR) and some studies report that it is present at diagnosis. Systemic inflammation has been pointed out as the reason. However, data on polymyalgia rheumatica (PMR) are controversial. Objectives: To analyse IR in a group of untreated patients with a recent diagnosis of RA and PMR, and to establish predictive factors related with IR. Methods: Longitudinal observational study of patients older than 60 years, newly diagnosed with elderly-onset AR (ACR/EULAR 2010) and PMR (ACR/EULAR 2012). Comparison with healthy control group of the same age. Inclusion: consecutive and voluntary. Exclusion: patients with insulin-dependent diabetes. Follow-up time: 12 months. The clinical-epidemiological, anthropometric and analytical characteristics were collected. IR was calculated by HOMA-IR [(homeostatic model assessment of insulin resistance) = glucose (mg/dL) * insulin (mUI/L)/405] baseline and at 12 months. HOMA-IR>2.75 was considered IR (according to Spanish data). The statistical study was performed with Stata 15.1. Results: We recruited 42 patients with RA, 18 with PMR and 18 healthy controls. None of them had received treatment with corticosteroids or with DMARD at the baseline visit. Baseline characteristics are summarized in the table. At baseline visit, 66.7% of patients with elderly-onset RA had IR, compared with 33.3% of controls (p=0.024) and 27.8% of PMR (p=0.006). Therefore, the prevalence of IR in patients with RA doubled that of controls and patients with PMR before starting treatment. After 12 months of evolution and treatment, patients with RA and IR decreased from 66.7% to 51.2%, not being statistically significant (p=0.179). On the other hand, the percentage of patients with PMR and IR remained the same (27.8%). The differences in IR between RA and PMR at 12 months remained statistically significant (p=0.048). Given the results we decided to analyze the predictive factors related with IR only in the 42 patients with RA. In the univariate logistic regression analysis, the predictors of presenting IR were the BMI, the abdominal perimeter and the scapular girdle involvement. Specifically for BMI, for each of 2 kg/m2 the probability of having IR was 1.24 times higher (OR=1.24, IC95%: 1.12-1.37). Patients with scapular girdle involvement had a 6-fold increased risk of developing IR (OR = 6.0, 95% CI: 1.3-26.6). And for every 5 centimetres of abdominal perimeter the risk increased almost 4 times more (OR=3.9, 95% CI: 2.9-5.1). In the multivariate analysis, the only independent factor to increase the IR was the abdominal perimeter (aOR = 1.23, IC95%: 1.07-1.41). Conclusion: Patients with elderly-onset RA have a higher IR than the general population. High IR in RA is present at diagnosis. IR in AR is not exclusively mediated by systemic inflammation, since patients with PMR do not have this increase. The predictors of presenting IR in late onset AR were BMI, scapular girdle involvement and abdominal perimeter. Only the abdominal perimeter was shown as an independent factor. Disclosure of Interests: None declared

Background: Adult-onset Still’s disease (AOSD) is an uncommon disease with an unpredictable clinical course and variable prognosis. Sometimes, it requires biologic treatment in early phases. A prognosis score has been described, which has never been applied in a Spanish case series. Objectives: To apply the prognosis score described by Pouchot et al (Systemic Score System (SSS)) on a 64 cases series diagnosed with AOSD in Spanish population and to determine if SSS high values registered at the onset of the pathology are related to AOSD clinical patterns (monocyclic, polycyclic and chronic course), requirement of biologic treatment along the disease’s course and development of AOSD clinical complications. To establish the relationship between its value and the AOSD-related mortality. Methods: Retrospective study realized in two University Hospitals. Clinical, laboratory, AOSD-related complications data, administered biologic treatments and number of deaths (AOSD related or not) were recorded. Each patient was characterized for the presence of AOSD-related complications such as macrophage activation syndrome (MAS), myocarditis, lung involvement (pulmonary hypertension, interstitial infiltrate), renal involvement (tubulointerstitial nephritis, acute renal failure), secondary amyloidosis and AOSD-related death. SSS was applied at the onset of the disease development, assigning a point to each of the next 12 variables: fever, exanthema, pleuritis, pneumonitis, pericarditis, alteration of liver tests or hepatomegaly, splenomegaly, lymphadenopathy, odynophagia, leukocytosis >15,000/mm3, myalgia and abdominal pain. A ≥7 score has been validated on other populations as the one which identifies the patients with high risk of complications. The relationship between SSS value and the next parameters was determined: clinical course, complications, biologic treatments administered and AOSD-related mortality. Results: Data from 64 patients was analyzed (40,6% men, mean age 37 years). SSS values of Conclusion: The prognosis score described by Pouchot et al could be useful to identify those patients with high risk of developing clinical complications and those who will need biologic treatment along the course of their disease. It is necessary a higher number of patients to determine if the score could be useful to estimate the death risk related to AOSD complications. References: [1] Ruscitti, et al. Adult-onset Still’s disease: evaluation of prognostic tools and validation of the systemic score by analysis of 100 cases from three centers. BMC Medicine (2016)14:194 Disclosure of Interests: Ivette Casafont-Sole: None declared, Susana Holgado: None declared, J. Narvaez Consultant for: Bristol-Myers Squibb, Maribel Mora: None declared, Josep Roca: None declared, Anahy Brandy-Garcia: None declared, Lourdes Mateo: None declared, Melania Martinez-Morillo: None declared, Laia Gifre: None declared, Maria Aparicio Espinar: None declared, Agueda Prior-Espanol: None declared, Anne Riveros: None declared, Clara Sanguesa: None declared, Jordi Camins-Fabregas: None declared, Annika Nack: None declared, Joan Miquel Nolla: None declared, Alejandro Olive: None declared

Background Polyarthritis at the elderly people usually has a similar onset with an acute inflammatory character and scapular girdle involvement. Differentiating elderly onset rheumatoid arthritis (EORA) and polymyalgia rheumatica (PMR) can be a diagnostic challenge. Objectives To analyse the clinical and analytical differences between EORA and PMR. Methods Longitudinal observational study of patients older than 60 years newly diagnosed with EORA (ACR/EULAR 2010) and PMR (ACR/EULAR 2012). Inclusion: consecutive and voluntary. Follow-up time: 12 months. A single rheumatologist made all follow-up visits. The clinical-epidemiological and analytical characteristics were collected. The statistical study was performed with Stata 15.1. Results 45 EORA were recruited (53% women; mean age 74.8 ± 7.5) and 20 PRM (85% women; mean age 76.6±5.0). 75% of EORA had scapular girdle involvement, but only 44% of the pelvic girdle. All had peripheral arthritis, and the small joints of the hands were involved in 93.3%, with edema in 46.7%. Forty percent of EORA patients were seropositive (RF> 20 IU/mL and/or ACPA> 20 U/mL): 33% RF positive (132.8 ± 126 IU/mL), 28.9% for ACPA (2 cases [15.4%] from 100 to 250 U/mL and 11 cases [84.6%] above 250 U/mL) and in 10 patients [22.2%] double positive). All patients with PMR patients had shoulder girdle involvement and 90% of the pelvic girdle. None of them had peripheral arthritis. RF was positive in one patient (73 IU/mL) and ACPA in 2 patients (titers between 20-40 U/mL). No patient was double positive. Table 1 and 2. After 12 months of follow-up, there was no difference between the dose of glucocorticoids received in patients with EORA and PMR (p = 0.684). There were also no differences in glucocorticoids adverse effects according to the diagnosis (p = 0.734). Regarding the use of immunosuppressors, this was higher in patients with EORA (91% EORA and 20% PMR), according to the usual clinical practice guidelines. The percentage of remission in PMR at 12 months was 95%. However, using DAS 28-VSG, only 40.9% of patients with EORA were in remission at 12 months (p=0.003). Conclusion The female predominance was higher in PMR than in EORA. The scapular girdle involvement, but especially the pelvic girdle, was more frequent in PMR. In contrast, involvement of peripheral joints and edema were more frequent in EORA. RF and ACPA were more frequent in EORA. There were no other analytical differences that would help their differential diagnosis. The mean and accumulated doses of glucocorticoids during the first 12 months were similar, as well as the percentage of side effects. Immunosuppressors are more frequently used in EORA than in PMR. Remission is achieved more commonly in PMR than in EORA. References [1] Olivieri I, Pipitone N, D’ Angelo S, Padula A, Salvarani C. Late-onset rheumatoid arthritis and late-onset spondyloarthritis. Clin Exp Rheumatol 2009;27(4 Suppl 55):S139-145. [2] Pease CT, Haugeberg G, Montague B, Hensor EMA, Bhakta BB, Thomson W, et al. Polymyalgia rheumatica can be distinguished from late onset rheumatoid arthritis at baseline: results of a 5-yr prospective study. Rheumatology 2009;48(2):123-7. Disclosure of Interests None declared

Background Elderly onset rheumatoid arthritis (EORA) has several peculiarities. Which activity index should we use in this age group is still an unresolved issue. The use of ESR in DAS28 is widespread, but it is well known that ESR could increase with age, overestimating activity. DAS28-PCR or SDAI, which uses PCR, or CDAI that does not use analytical data, could be more suitable alternatives. Objectives To describe disease activity scores evolution in EORA and to analyse the correlation and concordance between them. Methods Longitudinal observational study in naive treatment EORA patients (ACR/EULAR 2010 criteria). Study visits were carried out basally (pre-treatment) and at month 1, 3, 6 and 12. DAS28 VSG, DAS28 PCR, SDAI and CDAI were calculated at each visit, and ACR/EULAR remission index at 12 months. The same rheumatologist made all visits and explorations. Correlations were analysed using the Spearman or Pearson correlation index (p value ≤ 0.001). The concordance was evaluated with the kappa index. The statistical study was performed with Stata 15.1. Results 45 patients with EORA were enrolled. Table 1 and 2 summarize the clinical and analytical characteristics. All the scores had a very good linear correlation both at baseline and at follow-up (correlation score: 0.83-0.98). A moderate concordance was observed from the baseline visit between DAS28-VSG and DAS28-PCR (k=0.43-0.52, p Conclusion The correlation between the different scores was good. However, the concordance between all the scores decreases as time passes, according to a higher percentage of patients in remission or low activity. This low-moderate concordance is demonstrated even between DAS28-PCR and DAS28-VSG, and when these are compared with CDAI and SDAI. CDAI and SDAI are the only ones that maintain a good concordance between them, even when the number of patients in remission or low activity increases. ACR/EULAR only maintains an acceptable concordance with the most restrictive scores, SDAI and CDAI. By contrast, agreement is very low with DAS28, especially by DAS-PCR. Disclosure of Interests None declared

Background Elderly-onset RA (EORA), which is defined as rheumatoid arthritis (RA) with an onset at >60 years of age, and polymyalgia rheumatica (PMR) are common rheumatic diseases in the elderly. Eicosanoids are biological lipids that serve a specific role as either activators or suppressors of systemic inflammation and have been involved in the development and progression of arthritis. Objectives We hypothesized that eicosanoid-related perturbations are related to arthritic symptoms in the elderly, and that by defining this eicosanoid profile, we might be able to define elements of inflammation pathobiology in this population. Methods Arthritis in the Elderly (ARTIEL) is a recent collection cohort with patients older than 60 years of age who have newly diagnosed arthritis. Blood samples were collected from these patients at baseline (pre-treatment) and 3 months after treatment, along with physician and patient outcome measures through 12 months. These patients were also compared with randomly-selected control individuals of the same age and gender. A thorough clinical examination was conducted and patients completed a health assessment questionnaire (HAQ). Disease activity score (DAS)28CRP was also calculated. Serum eicosanoids were determined by mass spectrometry at baseline and after 3 months of treatment and were classified into groups according to their eicosanoid precursors: eicosapentaenoic acid (EPA), docosohexanoic acid (DHA) or arachidonic acid (AA). Data processing and statistical analysis were performed in R. Results 64 patients (average: 75.15, standard deviation (SD) 6.80) and 18 controls (average: 75.39, SD, 6.04) were analyzed. Of these, 44 were diagnosed with RA and 20 with PMR. At the start of the study, patients had a mean DAS28CRP of 5.72 (SD, 1.05) and a mean HAQ of 1.64 (SD, 0.73). In addition, 84% of the patients reported scapular pain and 56% reported pelvic pain at baseline. After three months of treatment, patients had a mean DAS28CRP of 2.38 (SD, 1.23) and a mean HAQ of 0.36 (SD, 0.41). Several eicosanoids, especially anti-inflammatory species derived from EPA and DHA, were significantly downregulated in both RA and PMR patients at the start of the study as compared to normal controls (Figure 1). Three months after treatment, the levels of anti-inflammatory eicosanoid species derived from EPA and DHA went back to normal only in patients who responded to therapy. Conclusion These results suggest that certain eicosanoids may be key effectors in arthritis in the elderly and that the imbalance between pro and anti-inflammatory eicosanoids before and after treatment might be related to clinical and therapeutic outcomes in this population. References [1] A systematic review on the role of eicosanoid pathways in rheumatoid arthritis. Hoxha M. Adv Med Sci. 2018 Mar;63(1):22-29. [2] Kobak S, Bes C. An autumn tale: geriatric rheumatoid arthritis. Therapeutic advances in musculoskeletal disease. 2018 Jan;10(1):3-11. PMID: 29290762 [3] Quehenberger O, Dennis EA. The human plasma lipidome. New England Journal of Medicine. 2011 Nov 10;365(19):1812-23. PMID: 22070478 Disclosure of Interests Roxana Coras: None declared, Rekha Narasimhan: None declared, Arthur Kavanaugh Grant/research support from: UCB Pharma, Lourdes Mateo Soria: None declared, Oswald Quehenberger: None declared, Monica Guma: None declared, Melania Martinez-Morillo: None declared

Background Clinical manifestations of systemic lupus erythematosus (SLE) and infections sometimes are difficult to distinguish. In clinical practice low complement and anti(ds)DNA levels are used to assess lupus activity but its determination usually requires some days. Leukocyte count, CRP and ESR cannot discriminate SLE from infectious processes. Calprotectin could be a good biomarker to assess lupus activity since it is more specific than CRP and ESR and faster to analyse than anti(ds)DNA. Objectives Our aim is to determine serum calprotectin levels in patients with SLE, and its correlation with analytical and clinical manifestations, especially with disease activity. Methods A total of 148 patients were included. All patients included fulfilled the SLE criteria (SLICC 2012). A quantitative ELISA analysis was performed to assess levels of serum calprotectin (CALPRO AS, Norway). Other biomarkers of lupus disease activity were also assessed (levels of anti(ds)DNA, hypocomplementemia, ESR and CRP). Clinical variables and activity/damage index (SLEDAI/SLICC) were also evaluated. The study was approved by the Clinical Research Ethics Committee of the hospital and all patients signed an informed consent. The results were compared with a healthy control group of similar age and sex (n=20). Results 134 patients (92%) were women with a mean age of 46±12 years and an average SLE evolution of 12±7 years. Mean SLEDAI was 2±2 (105 inactive [ 13]). Mean SLICC was 0.31±0.70. No significant differences were observed in serum calprotectin levels between patients with SLE and healthy controls (2.93±2.35 vs 2.17±1.49 µg/mL, p=0.160). Calprotectin was positively correlated with CRP (r=0.447, p= 100UI/mL) had higher calprotectin compared to patients with lower anti(ds)DNA (3.20±2.63 vs 2.42±1.57 µg/mL; p=0.027), however this pattern was not observed with hypocomplementemia. Contrary to what we expected, we did not observe significant differences on calprotectin levels depending on SLEDAI index classification (cutoff at 4 and 12). Moreover, no differences were observed on calprotectin levels between those patients with/without clinical manifestations such as serositis, arthritis or glomeruloneprhitis. Patients with antiphospholipid antibodies had higher calprotectin levels (3.75±2.04 vs 2.77±2.38 µg/mL;p=0.045). Conclusion Serum calprotectin levels were positively correlated with CRP levels and leukocyte count. Patients with higher anti(ds)DNA levels had higher calprotectin levels, however we did not observe significant differences depending on SLEDAI index or the presence of arthritis, serositis neither glomerulonephritis. Even that calprotectin determination is faster than anti(ds)DNA levels and could be helpful in assessing inflammatory activity. There is an interesting relation between antiphospholipid antibodies and calprotectin. This study should be continued in a larger sample of active SLE patients to assess its utility in clinical practice as a discriminating biomarker for flares and even infection Disclosure of Interests None declared

Background: Dermatomyositis (DM) is an idiopathic inflammatory myopathy. The recent years has increased its knowledge thanks to best characterization of myositis-specific antibodies that correlate with different clinical phenotypes.with different clinical phenotypes. Objectives: To describe the clinical and analytical features of a series of dermatomyositis: clinical debut, clinical manifestations as well as the treatments received and the evolution of the disease. Methods: Patients diagnosed of dermatomyositis in a tertiary hospital between the years 1978-2018 according to the criteria of Bohan and Peter (1975) and according to Dalakas’ classification criteria (2015). Clinical, analytical and immunological profile data were collected, as well as treatments received and the evolution of the disease. Results: A total of 59 inflammatory myopathies diagnosed between the years 1985 and 2018 were included. 46 were dermatomyositis (78%), 9 polymyositis (15%) and 4 necrotizing myositis (7%). 69% were women and 22% were smokers. Clinic started at 54 ± 17 years. The initial manifestation was pulmonary in 26.7% followed by cutaneous manifestations (24.4%) and the muscular (22.2%), while a 17.8% started skin and muscular manifestations at the same time. 45.5% behaved like a myopathic DM while a 28% as amyopathic DM and antisynthetase syndrome respectively. 38% presented interstitial involvement being the most common non-specific interstitial pneumonitis (76%)followed by usual interstitial pneumonitis (17%). In these patients, DLCO was decreased (mean of 58.9% and 13.2) as well as the FVC (average of 58%, 2.5L). 73.3% presented cutaneous involvement being the most common manifestations the Gottron papules (37.8%) and the heliotrope rash (35.6%), and up to 27% had cuticular affectacion. 64% had muscle involvement, afecting proximal and symmetrical. Neck flexors were affected in a 38% of patients while 20% had dysphagia.Only 3 patients presented dysphonia (7%) and 2 myocarditis Analytical data Conclusion: 80% received corticotherapy at a dose of mg/kg/day and 20% required high doses of metilprednisolone due to muscular involvement or pulmonary. 18% immunoglobulins and 11% cyclophosphamide. As maintenance 80% received disease modifiying antirheumatic drug in addition to corticosteroid therapy in descending doses (azathioprine 22%, dolquine 15%, tacrolimus 13.3%, rituximab 11%) due to muscle (29.9%), cutaneous (24.4%) and pulmonary involvement (22.2%). As complications, 2 cases of the syndrome were registered hemophagocytic Virtually all patients they presented pulmonary hypertension (mean 34 ± 12 mmHg). 5 patients (11.1%) were diagnosed with neoplasia, two of them after the diagnosis of DM. The mortality was 24%. 3 patients died due to a rapidly progressive pneumonitis, another 2 due to alveolar hemorrhage and three of them due to complication of the neoplastic disease. Dermatomyositis occurs in a variable way, with predominance of pulmonary, skin and muscle manifestations. They require corticotherapy and immunosuppressive treatment for maintenance, even so, mortality is high. Disclosure of interests: None declared

Background Extra-articular manifestations (EAM) in rheumatoid arthritis (RA) are more prevalent in patients with seropositive, nodular and long term disease. Around 40% of patients with RA can develop EAM, although the incidence has decreased with the “treat to target” strategy. Objectives To describe EAM in a cohort of patients with rheumatoid arthritis. Methods Retrospective descriptive study of patients diagnosed with RA between 2000 and 2018 who are currently under active biological treatment. Cardiovascular risk factors, baseline characteristics of RA and EAM during their evolution are collected. Statistical analysis is performed with SPSS 24. Results We recruited 108 patients, 81.5% female, with mean age at onset of RA of 50 ±15 years (range 17-82). RF was positive in 84.3% and ACPA in 81.3%. Erosions were observed on hands or feet at diagnosis in 35.2%. Mean follow up period: 12±8 years. The most common initial treatment was methotrexate (82.4%) and 44.4% received other DMARDs: leflunomide (32.3%), hydroxychloroquine (16.2%) and others (9.1%). DAS28VSG at diagnosis was 4.15±1.18 (1.89-6.02) and at the introduction of the first biological drug it was 5.02 ±1.16 (mean years since diagnosis 6±5). The first biological drug was etarnecept (40.7%), followed by adalimumab (17.6%), abatacept (15.7%), rituximab (7.4%), tocilizumab (7.4%) and infliximab (4.6%). 57.4% discontinued the first biologic: secondary failure (58.1%) or adverse effects (20.6%). 65.7% (71 patients) developed some EAM during disease evolution and 14.8% appeared during the first year. During this first year, secondary Sjogren (37.5%) was the most frequent, followed by rheumatoid nodules (18.7%), EPID (18.7%) and osteoporosis (18.7%). Two or more EAMs were present in 33.3% of patients. Fifty-four patients (56.3%) did not present any EAM at the beginning of the biological treatment and 29.6% (21 patients) developed EAM afterwards, with an average of 1±3 years. Pulmonary involvement was the first EAM to appear after the onset of biological treatment, followed by anemia (both in the first year). Summarizing the data of all patients over time, the most frequent EAMs were: osteoporosis (28.7%, mean appearance: 5 years from diagnosis); secondary Sjogren syndrome (27.8%, mean 6 years); normochromic normochromic anemia (21.3%, mean 8 years) and pulmonary involvement (17.6%, mean 4 years), presented as EPID (63.3%), NINE (25%), NIU (8.3%) and pulmonary nodules (8.3%). Other EAM observed were: cutaneous involvement in the form of rheumatoid nodules (15.7%, mean 5 years); ophthalmological involvement (6.5%, mean 18 years) (PUK 2.8%, uveitis 1.9%, scleritis 0.9%, episcleritis 0.9%); amyloidosis (3.7%, mean 16 years) and vasculitis (2.4%, mean 14 years). Conclusion EAM have a high prevalence in RA patients receiving biologic treatment (76.6%). A third part of patients had 2 or more EAMs. 14.8% develop the first EAM during the first year of evolution of RA and 30% in the first 5 years. The most frequent are osteoporosis and Sjogren’s syndrome, according to what is described in the literature. Pulmonary involvement is the most rapid during the evolution of RA with an average of 4 years. References [1] Marcucci E, Bartoloni E, Alunno A, Leone MC, Cafaro G, Luccioli F, et al.Extra-articular rheumatoid arthritis. Reumatismo. 2018Dec20;70(4):212-224 Disclosure of Interests None declared

Background Cardiac block in neonatal lupus is associated with placental transfer of anti-Ro antibodies. The effect of these antibodies on cardiac conduction disorders in adult patients is controversial. The association between anti-Ro antibodies and heart rhythm disorders have been described in isolated cases. However, there are just a few studies that analyse the relationship between autoimmune diseases and electrocardiographic disturbances. Objectives To determine if there are differences in cardiac conduction of SLE patients in presence of anti-Ro antibodies. Methods All patients included fulfilled the SLE criteria, SLICC 2012 and they were followed up in a single centre. The inclusion was consecutive and voluntary. Patients who took drugs that altered the conduction (except antimalarial drugs), and those who had heart or thyroid disease were discarded. All patients were assessed blindly by a cardiologist who performed an interrogation and physical examination, an electrocardiogram, an echocardiogram and a 24 hour Holter study. Besides, a rheumatologist performed a clinical and analytical assessment including a qualitative analysis by immunoblotting of anti-Ro Ab and a quantification by chemiluminescence of the anti-Ro52 and Ro60 Ab. The presence of other SLE specific Ab (ANA, DNA, antiphospholipids), was also analysed. Clinical, analytical and, activity and damage indexes, were collected (SLEDAI and SLICC). The data were compared by Student’s t test, Fisher’s test and Chi square using 21 SPSS version. The level of significance was established at 5%. Results 145 patients were included: 91.7% women, average age 45±12, average disease duration 11 years. The patients were undergoing the following treatments: antimalarial 91%, mycophenolate 20%, azathioprine 12%, biological treatment 5% and glucocorticoids 70%. The clinical characteristics are summarised in table 1. There were no significant differences between the group of positive and negative anti-Ro Ab in terms of gender, age, clinical characteristics or cardiovascular risk factors. None of the patients was affected by an atrio-ventricular block and the rest of the electrocardiographic alterations had no clinical significance and did not predominate in the positive Ro Ab group. Additionally, no differences in heart rate, ventricular extrasystoles or PR, QT or QRS intervals were detected between both groups. The echocardiogram’s findings were not relevant and there were no differences between groups. Since the majority of patients with SLE are double positive, differences between the two subspecificities of Ro (52 and 60) could not be analysed. On the other hand, no differences were found in cardiac conduction regarding the treatments received, the activity or damage indexes, or the analytical or clinical characteristics of the patients. Conclusions The study results show that there are no differences in cardiac conduction according to the presence of anti-Ro antibodies in SLE patients. Thus, the cardiac screening in SLE patients with anti-Ro positive antibodies seems not helpful in clinical practice. Disclosure of Interest None declared

Background There are few recent large cohort epidemiological studies that analyse the clinical profile of patients with psoriatic arthritis (PsA) who require biological treatment, as well as pharmacological survival and reasons for the suspension of these treatments. Objectives To describe the clinical, demographic, epidemiological and radiographic characteristics of patients with PsA in our centre, as well as pharmacological survival and reasons for the suspension of different biological treatments. Methods Retrospective analysis of patients with PsA treated between 1985 and 2015 at a University Hospital with a referral area of 8 50 000 inhabitants. Demographic, clinical, laboratory and imaging data, as well as patients’ clinical and medical treatment records. Results The main characteristics of the cohort are summarised in table 1: Approximately one third of patients with PsA (32.3%) required treatment with a biological drug during the course of their disease. The most frequently prescribed first-line drugs (89.5%) were tumour necrosis factor-α inhibitors (TNFi). During the course of their disease, 27 (21.9%) patients who started biological treatment received a biological drug other than TNFi. Of the 124 patients who started treatment with a biological DMARD, more than half (65, 52.8%) required a change to a second drug, and of these, 27 (41.5%) changed to a third, with up to 7 different biological drugs required in one case. The mean survival time for the first bDMARD was 42.8±42.3 months, with secondary failure the most frequent cause of treatment change (37.8%), followed by adverse effects (27.1%) and primary failure (18.9%). The adverse effects registered were: 20% infections, 20% appearance of neoplasms, 5% allergic reactions and 55% other causes. Conclusions PsA presents a similar distribution by sex and is usually diagnosed at around the age of 50, having been preceded by cutaneous involvement. PsA is an entity of considerable severity and up to a third of patients will require biological treatments during its evolution. More than half of them will receive a second biological treatment. The retention rate of each drug varies but tends to decrease with each drug change. Disclosure of Interest None declared

Background Pulmonary affection is a serious complication in Rheumatoid Arthritis (RA) with an important impact on mortality and morbidity. Objectives To describe the clinical and radiographic characteristics of patients with RA in our centre, and specifically from those with interstitial lung disease (ILD). Methods Retrospective analysis of patients with RA and pulmonary affection from a University Hospital with a referral area of 85.000 inhabitants. Clinical, laboratory, imaging and pulmonary function test (PFT) data was recorded. Results Data from 85 patients, 37 (43.5%) male and 48 (56.5%) female, were recorded. The mean time from RA diagnosis to pulmonary disease was 9.2 years, with mainly erosive (58.8%) and seropostive (84.7% were positive rheumatoid factor (RF) and 84.2% anti-citrullinated protein antibodies (ACPA)) disease. The 56.5% of the patients were smokers or ex-smokers. PFT results were documented in 75.3% of the patients: diffusing capacity for carbon monoxide (DCLO) baseline values were over 60% in a 38.8% of cases and forced vital capacity (FVC) baseline values were over 50% in a 69.4% of patients. The most frequent High Resolution CT scan pattern was the presence of bronchiectasis (64.7%), followed by ILD (31.8%) and, specifically, the Usual Interstitial Pneumonia pattern (UIP, 66.6%); lung infections (25.8%), rheumatoid lung nodules (22.4%), pleural effusion (15.3%), lung tumours (9.4%) and bronchiolitis (5.8%). The presence of extra articular manifestations as rheumatoid nodules (27%), epieschleritis (2.3%) and vasculitis (9.4%) was registered. The coexistence of Chronic Obstructive Pulmonary Disease (COPD) was recorded too (24.7%). Related to treatment, 84.7% of patients had received Methotrexate and in a 40% of cases, at least one biological disease-modifying antirheumatic drug had been administrated. Though the causes were not registered, a 25.9% of deaths were documented. In parallel we did a subanalysis of ILD related to RA cases, summarised in table 1 (n=27): Conclusions Bronchiectasis is the most common pulmonary manifestation of RA patients in our area. The most frequent clinical profile is a non-smoker woman with seropositive disease. ILD affects approximately one third of RA patients in our area and is an underdiagnosed entity. We consider that it is necessary to establish a screening program to diagnose and treat it early. Disclosure of Interest None declared

Background Septic arthritis (SA) is a rheumatologic emergency as joint destruction occurs rapidly and can lead to significant morbidity and mortality. Accurate diagnosis can be particularly challenging in patients with underlying inflammatory joint disease. Crystal-induced arthritis (CA) is a risk factor for its appearance. When both conditions appear simultaneously, CA may mask diagnosis of infection and delay the antibiotic treatment. Objectives To describe the characteristics of patients with concurrent septic and CA. Methods Retrospective analysis of patients with coexistence of septic and CA attended between 1985 and 2015 in a university hospital with a reference area of 850,000 inhabitants. We collect demographic, clinical, laboratory and imaging data as well as patient medical treatment, complications and evolution records. All patients had positive bacterial culture (blood and/or joint fluid) and crystals in synovial fluid. Results A total of 123 patients with SA were identified. 20.3% (n=25) of them had concomitant CA, with mean age of 67 years (SD 14), 17 (68%) males and 8 (32%) females. Risk factors were: diabetes (24%), diuretic drugs (24%), chronic renal failure (16%) -2 of them undergoing hemodialysis and 4 kidney transplant patients with immunosuppressive treatment. In only 2 cases there was a previous arthrocentesis. The mean diagnostic delay was 14 days (SD 13) (data available in 14 cases). The most commonly affected joint was the knee (48%), followed by the foot (20%) and the hip (12%). In 2 cases several joints were involved at the same time. In synovial fluid cytological studies, the most frequently identified crystals were: urate (60%), calcium pyrophosphate (20%) and hydroxyapatite (8%). In 32% of cases gram staining was positive, but 88% of patients had a positive joint fluid culture, with the most frequently isolated germs being methicillin-sensitive S. aureus (48%), methicillin-resistant S. aureus (MRSA) (12%) and M. tuberculosis (12%). 32% of patients presented positive blood cultures (12% with negative synovial fluid culture), although 48% of patients had fever at the time of diagnosis. It should be noted that 48% had radiological baseline damage. Surgical debridement was performed in 32% of patients. Evolution was successful in 56% of patients; although intercurrent complications were usual (40%). Mortality was 8% -one case due to acute pulmonary edema and the other because of septic shock. Conclusions Coexistence of infectious and CA represents a diagnostic challenge and requires a high suspicion index. It usually appears in elderly patients with comorbidities. Gout was the most prevalent CA. S. aureus was the most commonly causative pathogen, with a high rate of MRSA infection. If it9s treated early the evolution is usually favorable, which makes synovial fluid microbiological study imperative. Disclosure of Interest None declared

Background Anti-Ro antibodies (Ab) are especially directed against two antigens, Ro52 and Ro60, with different structure and function. Studies in systemic lupus erythematosus (SLE) have been described a relationship between the presence of anti-Ro Ab and dry syndrome, subacute cutaneous lupus, myocardial involvement or minor renal involvement. However, studies about the clinical usefulness of determining the 2 specificities of anti-Ro Ab in SLE are not conclusive. It seems that anti-Ro52 could be associated with joint involvement and lung disease, while anti-Ro60 could be related to late-onset SLE. In this paper we evaluate the clinical usefullness of anti-Ro52 and Ro60 Ab chemiluminescence quantification in patients with SLE. Objectives To analyze the presence of anti-Ro52 and Ro60 Ab in a cohort of patients with SLE and evaluate its correlation with clinical, analytical and immunological parameters. Methods 152 patients with SLE (according to the SLICC criteria 2013) attended in an university hospital were included. Qualitative immunoblot analysis of anti-Ro Ab was performed on all of them; those with positive values were also assessed by a chemiluminescence quantification of anti-Ro52 and Ro60 Ac (normality Results 91% (138) were women with a mean age of 46±12 years (range, 20–75) and an average SLE evolution of 12±7 years (range, 1–40). 32% (49/138) of the patients had anti-Ro positive determination by immunoblot: 36 were anti-Ro52 positive (mean value 696±726 CU) and 48 anti-Ro60 positive (mean value 504±696 CU) by chemiluminescence. Only one anti-Ro52 positive patient was anti-Ro60 negative. 10.5% had late-onset SLE. The mean SLEDAI was 1.84±2.48 while the SLICC was 0.32±0.7, with a mean anti(ds)DNA Ac values about 207.87±357.15 IU/ml. 37.5% had hypocomplementemia. Anti-Ro positive patients by immunoblot had a higher value of anti(ds)DNA compared to the patients without Ro positive values and patients with both positivity by chemiluminescence had lower prevalence of APS, however the quantitative values of anti-Ro52 and anti-Ro60 were not related with clinical, analytical or immunological parameters. Conclusions 32% of patients in the cohort were anti-Ro positive being mostly anti-Ro60 positive. The presence of anti-Ro Ab was associated with higher value of antiDNAds and lower prevalence of APS. However, the quantitative values of anti-Ro52 and anti-Ro60 Ab by chemiluminescence were not related to the different parameters analyzed in the study. These results indicate the need to assess the quantification of anti-Ro Ab in a larger cohort of patients with SLE. Disclosure of Interest None declared

Background The analysis of synovial fluid is an important tool for diagnosing joint disease. When synovial fluid is removed, the white cell count (WCC) decreases with time, and an inflammatory liquid could become a false non-inflammatory specimen. Reagent strip testing of urine is a valid tool for the diagnosis of urinary tract infection, via the detection of leukocyte esterase activity. It has been used for the analysis of others body fluids. Synovial fluid test at the site of arthrocentesis using reagent strips could have potential benefits as a screening tool. Objectives To evaluate the performance of leukocyte esterase reagent strips for diagnosis of inflammatory synovial fluid. Methods Prospective single center study. We analyzed synovial fluids samples collected from patients in a tertiary university Hospital (November 2015- December 2016). Synovial fluid samples were tested within 1 hour after collection. We analyzed: The presence of leukocyte esterase using the leukocyte esterase reagent strips test (originally designed for urine test, URI-Clip Test, Menarini Diagnostics). It was recorded semi quantitatively: negative, 1+ (>25 WBC/uL), 2+ (>75 WBC/uL) or 3 +(>500 WBC/uL) by comparison with a standard color chart found on the container9s label. The WCC, formula, glucose level. The WCC was measured by manual leukocyte counting, using saline as diluents. Cultures were also collected. We consider + if leucocyte esterase pad was more or equal than 1+ positive. The cut-off for the WCC (>2000cells/mm3) was used to differentiate between inflammatory and non-inflammatory specimens. We compared the WCC (reference standard diagnostic test) with the presence of leukocyte esterase using the leukocyte esterase reagent. Sensitivity (Se), specificity (Sp), PPV, NPV were determined. P-value smaller than 0.05 were considered significant. Results During the study period, 125 joint fluid specimens were analyzed: 56 (44.8%) mechanical and 69 (55.2%) inflammatory. Of the mechanical fluids 33 (58.9%) were negative by leukocyte esterase reagent and of the inflammatory fluids 67 (97.1%) were positive. The Se and Sp of leukocyte esterase reagent was 97.1% and 58.9% respectively. The PPV was 74.4% and NPV was 94.3%. The 2 false-negative results (negative by leukocyte esterase reagent but more than 2000 WBC/mm3), showed a predominance of mononuclears (> =91%), the median WCC was 2 775/mm and median neutrophil percentage was 8.5%. For inflammatory fluids: semi-quantitative results (negative, 1+, 2+ and 3+) were significantly different regarding the main leukocyte, neutrophil and lymphocyte count (table). Conclusions Our results demonstrate that leukocyte esterase reagent strips are a rapid, cheap, and sensitive tool to identify inflammatory synovial fluid. Leukocyte esterase reagent strips had an excellent Se but a poor Sp, it could be used as a screening tool in primary care practice. A positive result may indicate an inflammatory process, then the patient should be referred to a rheumatologist. Disclosure of Interest None declared

a b s t r a c t Background: Granulomatosis with polyangiitis (GP) is a necrotizing vasculitis of unknown etiology that involves small and medium caliber vessels. It is associated with anti neutrophil cytoplasm antibodies (ANCA). It most often affects the respiratory tract and the kidneys and its most important pathologic feature is the presence of necrotizing granulomas. Objectives: To detail the features of 15 patients with GP diagnosed in a university referral center. Patients and methods: Retrospective study: between 1984 and 2009, 15 patients with GP were diagnosed in our center. Epidemiological, clinical, laboratory test as well as pathologic studies and treatment were retrospectively analyzed. Biopsy diagnosis of GP was considered as an inclusion criterion. Results: Fifteen patients were diagnosed: 12 men and 3 women. Mean age at diagnosis: 52.2 years (14-78). 12 patients had a history of smoking. A biopsy was diagnostic in all patients. ANCA were positive in 11 cases, 6 had a cytoplasmic c-ANCA pattern. All patients had pulmonary involvement and seven (40%) had renal involvement. All patients received intravenous glucocorticoids and cyclophosphamide as induction therapy. During the disease progression 5 patients died.

Background Wegener's granulomatosis (WG) is a necrotizing vasculitis of unknown etiology that involves small and medium caliber vessels. It is associated with anti-neutrophil cytoplasm antibodies (ANCA). It most often affects the respiratory tract and the kidneys and its most important pathologic feature is the presence of necrotizing granulomas. Objectives To detail the features of 15 patients with WG diagnosed in a university referral center. Patients and methods Retrospective study: between 1984 and 2009, 15 patients with WG were diagnosed in our center. Epidemiological, clinical, laboratory tests as well as pathologic studies and treatment were retrospectively analyzed. Biopsy diagnosis of WG was considered as an inclusion criterion. Results Fifteen patients were diagnosed: 12 men and 3 women. Mean age at diagnosis: 52.2 years (14–78). Twelve patients had a history of smoking. A biopsy was diagnostic in all patients. ANCA were positive in 11 cases, 6 had a cytoplasmic c-ANCA pattern. All patients had pulmonary involvement and seven (40%) had renal involvement. All patients received intravenous glucocorticoids and cyclophosphamide as induction therapy. During the disease progression 5 patients died. Conclusion The clinical features of this series do not differ from those described by other authors. However, a history of smoking is more common than expected. Frequently used drugs were glucocorticoids and cyclophosphamide (oral and pulse therapy). The course was usually unfavorable, with outbreaks or complications due to immunosuppression, except for those with limited forms. Immunosuppressive therapy should be maintained indefinitely in most cases.

To the Editor: Transplacental transfer of anti-Ro antibodies is a well-known cause of conduction defects and permanent atrioventricular block in newborns.1 In adults, conduction disturbances related to these antibodies are rare.2 We report a case of a 26-year-old woman with no history of this condition who was admitted to the hospital through the emergency department after having several syncopal episodes. Electrocardiography (ECG) performed while the patient was at rest showed complete atrioventricular block and ventricular escape rhythm associated with left bundle-branch block (Figure 1A). Laboratory evaluation included a positive test for antinuclear antibodies (with the HEp-2 cell substrate) at a . . .

Background and objective Secondary amyloidosis (AA) is a rare complication of rheumatic diseases. Objective The aim of this study was to determine the frequency of symptomatic amyloidosis AA in patients with spondyloarthropathy. Patients and method Retrospective study (1984–2013). We reviewed the medical records of patients with spondyloarthropathy who had a histological diagnosis of amyloidosis AA (15 patients). Results We identified 1.125 patients with spondyloarthropathies. Fifteen (1.3%) patients with amyloidosis AA were recruited. It was suspected in 14 patients (93.3%) because of nephrotic syndrome in most of them: 14 were symptomatic (93.3%): 5 (33.3%) ankylosing spondylitis (AS), 5 (33.3%) spondylitis associated with inflammatory bowel diseases (IBD), 4 (26.7%) psoriatic arthritis, and one (6.7%) reactive arthritis. The mean disease duration was 23.9 years. Mortality after one and 5 years of follow-up was 30 and 50% respectively. Conclusions The frequency of clinical amyloidosis AA in our patients was 1.3%. There was a marked male predominance, with AS or IBD. Clinical amyloidosis was diagnosed at a relatively late stage in spondyloarthropathy.

Background Osteoporosis is defined as a systemic skeletal disease characterized by low mineral density and microarchitectural changes in the bone which increase its fragility and fracture risk. Ankle fracture is one of the most common fractures; however the relation with osteoporosis is still being debated. The diagnosis and treatment of osteoporosis is not always adequate. Objectives To determine the relation of ankle fractures to osteoporosis Methods Retrospective study 2008–2014. Center: Tertiary academic hospital with a referral area of 850,000 inhabitants. The medical charts, bone mineral density (BMD), radiographs and electronic data bases of patients with ankle fracture were reviewed. Demographic data (age, gender), BMD, mechanism of injury (high or low energy trauma), fracture pattern (single malleolus, bimaleollar and trimalleolar fracture) and treatment of fracture and osteoporosis were collected. Patients were divided into younger age (≤60years) and older age (>60 years) groups. Results A total of 299 patients with ankle fractures were included. The mean age was 49.5 years (DS 26.5). There were 131 (43.8%) male and 168 (56.2%) female patients. Among these patients, 84 (28.1%) were in the older age group (74% female and 26% male) and 216 (72.2%) were in the younger age group (51% male and 49% female). Bimaleolar fracture was the most common pattern in both groups (62.7% and 50.5%). Proportion of low energy trauma and conservative treatment was higher in elderly group compared to younger group (63.9% vs 38%, p 0.002/20.5% vs 8.3%; p 0.003). Of note 34 (11.7%) of patients underwent a dual-energy X-ray absorptiometry (DXA): 17 (50%) in the elderly group and 17 (50%) in younger (82% were older than 50 years). In the older group only 1 (5.9%) patient had a normal BMD, 8 (47.1%) had osteopenia and 8 (47.1%) had osteoporosis. Compared with younger patients, osteoporosis was more frequent in older group (10.8% vs 1.4%; p Conclusions Ankle fracture was more common in females in the older group. DXA was performed in a very low percentage of cases. The features of ankle fractures and the higher ratio of new fractures in the older group suggest a possible link with osteoporosis. Patients with ankle fracture should be studied in order to diagnose osteoporosis. These patients may have a benefit of treatment. Disclosure of Interest None declared

Background Systemic vasculitis (SV) comprises a group of diseases characterized by inflammation of vessels in various organs. Histopathological confirmation is required for the diagnosis. The biopsy of an involved organ is invasive and carries the risk of complications. By contrast, gastrocnemius muscle biopsy is simple and minimally invasive technique that may be performed by a rheumatologist. Objectives To evaluate the diagnostic use of muscle biopsies for the diagnosis of SV. Methods Retrospective study 1984 - 2015. Center: tertiary academic hospital, referral area 850.000 inhabitants. We analyzed the database of all muscular biopsies performed at our hospital. We selected patients undergoing a muscular biopsy for possible diagnosis of SV and we analyzed the clinical, laboratory, neurophysiological and pathologic data. Biopsies were classified as positive (presence of necrotizing vasculitis or non necrotizing vasculitis seen by optical microscopy) or negative for vasculitis. Muscular biopsy was performed in all cases at the medial gastrocnemius muscle (“open” and unilateral) by a rheumatologist. The diagnosis of SV was based on clinical, serological and histological data. Results A total of 619 muscular biopsies were performed, 55 were indicated with suspicion of SV, 52.7% female, 47.3% male, median age 64.4 years (DS 15.22); 47 (85.4%) were positive (sensitivity of 85%) and 8 (14.6%) were negative. The positive biopsy group showed more electromiographic alterations (p=0.01) than negative group. Furthermore, the positive biopsy group showed more frequently systemic manifestations such as: weight loss, myalgia, paresthesias, purpura and testicular pain but these differences were not statistically significant. No complications were encountered in the procedure. Conclusions Our results suggest that muscle biopsy is a simple, clinically useful, safe and minimally invasive procedure for the diagnosis of SV with high sensitivity. No significant differences were observed in clinical or analytical features between patients with positive or negative biopsy, except in electromyography patients with positive biopsy had more a frequent pathological pattern. Disclosure of Interest None declared

Background Osteoporosis is a major health problem worldwide and leads to several million fractures every year. Diabetes mellitus (DM) and obesity are an increasing threat for global health. While the pathophysiology of diabetic bone disease is unknown, some recent studies have demonstrated an increased fracture risk related to type 2 DM. Type 1 DM has also been associated with a decreased bone mineral density (BMD). Objectives To investigate the relationship between DM and obesity, and their relation to osteoporosis and ankle fractures. Methods Retrospective study 2008–2014. Center: tertiary academic hospital with a referral area of 850,000 inhabitants. The medical charts, dual-energy X-ray absorptiometry (DXA), radiographs and electronic data bases were retrospectively reviewed of patients seen for ankle fractures. Patients were classified in 4 groups: obesity (IMC>30), non-obesity, diabetic and non-diabetic. We compared demographic data (age, gender), mechanism of injury (high or low energy trauma), pattern of fracture (single malleolus, bimaleollar and trimalleolar), treatment of the fracture, presence of new fracture (in other localizations) and osteoporosis treatment Results We compared a total of 65 diabetic patients (32.3% male and 67.7% female, mean age 61.8 years [DS 17.6]) with 234 non-diabetic patients (52.9% male, 47.1 female, mean age 31.5 [DS 41.7]) and 40 obese patients (37.5% male and 34.7% female, mean age 42 years [DS 21.2]) with 76 non obese patients (38.2% male, 61.8% female). The main characteristics of the study groups are presented in Table 1. There were no differences in fracture pattern, mechanism of injury, BMD and fracture treatment among all groups. Bimaleolar fracture was the most common pattern in all groups. Diabetic group had higher frequency of a low energy trauma, osteoporosis and new fracture. New fracture was reported in 12 patients, between 3 and 48 months (after the ankle fracture). There was 5 Colles9fracture, 3 hip, 2 in other localization. One patient had two fractures (Colles and vertebral) Obese group had higher frequency of osteopenia compared with non obese. Conclusions We did not found statistical differences between diabetic and obese compared with non diabetic or non obese patients. Ankle fracture in diabetic group could have features of osteoporotic injury including the high frequency of new fracture. Disclosure of Interest None declared

Background Tocilizumab (TCZ) is a humanized anti-IL-6 receptor-blocking monoclonal antibody used for the treatment of rheumatoid arthritis (RA), idiopathic juvenile arthritis (IJA) and off-label in Adult Onset Still Disease (AOSD). The development of anti-TCZ antibodies could reduce treatment efficacy or induce treatment failure. Objectives To analyse TCZ serum levels and antidrug antibodies (ADA) in a cohort of RA, IJA and AOSD patients treated with TCZ, and to evaluate its relationship with Disease Activity Score using a 28-joint count (DAS28), C-reactive protein (CRP) levels and the presence of combined treatment with glucocorticoids or DMARDs. Methods Cross-section study including all patients undergoing chronic treatment with TCZ in a tertiary academic hospital. Referral area: 850,000 inhabitants. Twenty-two patients were included. TCZ serum and ADA levels were measured by ELISA (Theradiag) at baseline (before infusion), 15 days and 30 days after infusion. Results Twenty-two patients were studied: 18 RA, 3 IJA and 1 AOSD, 81.8% female; mean age and mean disease duration: 54.2 (±13) and 15.5 (±12) years respectively; 73% of the RA patients were positive for anti-CCP and 70% for rheumatoid factor, mean DAS28-CRP at day 0 and 30: 2.9 and 2.6 respectively. Fifteen patients were treated with TCZ for more than 1 year (range 12-58 months), 19 were treated with TCZ at 8 mg/kg, 2 at 6mg/kg, and one at 5mg/kg every 4 weeks due to low disease activity. Thirteen patients received TCZ in monotherapy, 9 received DMARDs combined treatment, 10 with glucocorticoids (mean dose 4mg/day, range 2-10mg). TCZ serum levels were at baseline: 1.2- 61.7 μg/ml, 15 days: Conclusions Levels of TZC were heterogeneous. Our patients showed no presence of ADA, this data suggest that TCZ has a low immunogenic potential. No correlation was found in disease activity and TCZ serum levels, but we found a relation with CRP levels. Patients with DAMRDs or without glucocorticoids showed higher levels of TCZ. We did not find correlation between combined treatment with DMARDs or glucocorticoids and levels of TCZ. Our study was limited due to a low sample size; we cannot exclude the correlation between TCZ and DAS28-CRP in a higher sample of patients. References Dougados M, Kissel K, Conaghan PG et al. Clinical, radiographic and immunogenic effects after 1 year of tocilizumab-based treatment strategies in rheumatoid arthritis: the ACT-RAY study. Ann Rheum Dis. 2014;73(5):803-9 Van Herwaarden N, Herfkens-Hol S, van der Maas A, et al. Dose reduction of tocilizumab in rheumatoid arthritis patients with low disease activity. Clin Exp Rheumatol. 2014;32(3):390-4 Disclosure of Interest None declared

Background Behcet9s disease is a recurrent systemic vasculitis which may have neurological manifestations: Neuro-Behcet (NB). The estimated frequency is 1-59%. It is more common in males. Central neurological system (CNS) involvement, presenting as pseudotumoral masses are very rare Objectives To describe the clinical characteristics, incidence, treatment, and outcome of patients diagnosed of pseudotumoral neuro-Behcet disease. We performed a systematic review of cases reported in the literature. Methods Desing: retrospective (1984-2014). Location: Two University hospitals. A hundred and fifty five patients records were reviewed with a diagnosis of Behcet9s disease from the Rheumatology service data base. Inclusion criteria: patients with pseudotumoral neuro-Behcet. A systematic search of all published cases with this diagnosis through PubMed was also performed. (1987-2014, keywords: pseudotumoral, neuro-Behcet) Results Three new cases of pseudotumoral Neuro-Behcet were identified. After a systematic review, other 27 cases were found with this diagnosis. The whole series were composed of 30 patients: a predominance of male (73.3%) was observed, with a mean age: 39.2±12.1 (range: 23-63 years). The mean duration of Behcet9s disease prior to the diagnosis of NB, was 9.3±7.8 years, in 50% of patients. The diagnosis was performed simultaneously or later in the remaining patients. The location of the lesion was: capsular thalamus region 15 (50%), peduncle and cerebellar 4 (13.3%), fronto parietal region 2 (6.7%), fronto temporal and temporo -occipital region in 1 (3.3%). Four (13.3%) patients presented more than one lesion. In 14 (46.7%) patients biopsy of the brain mass was performed in order to confirm the diagnostic. All reported patients were initially treated with high-dose of glucocorticosteroids (oral or intravenous), other immunosuppressive agents such as azathioprine, cyclophosphamide, methotrexate or chlorambucil were added. Three (10%) patients (2 of own serie and 1 described in literature) were treated with biological agents (anti TNF alpha, rituximab and tocilizumab). Only in one case plasmapheresis was performed because of refractory disease. Most patients showed progressive improvement, and three (10%) patients died. Conclusions The presence of pseudotumoral lesions is a very rare presentation of Neuro-Behcet. It is more common in males and occurs years after diagnosis; however it can also occurs simultaneously. A differential diagnosis with other CNS diseases and malignancy is mandatory. The response to glucocorticoides plus immunosuppressive drugs is good. Biological agents may be useful for refractory cases. Disclosure of Interest None declared

Background Rheumatoid vasculitis is an extra articular manifestation of rheumatoid arthritis (RA), that occurs during the course of long standing disease. It is associated with a poor prognosis Objectives To describe the clinical characteristics, incidence, treatment, and outcome of patients diagnosed with rheumatoid vasculitis (RV) at a Rheumatology service of a University hospital during the last 30 years Methods Retrospective study (1984-2014). Location: University hospital. Referral area: 850.000 inhabitants. Medical records of patients with diagnosis of RA were reviewed, from the Rheumatology service data base. Inclusion criteria: patients with RV with histopathological confirmation of vasculitis or high suspicion based on clinical or radiological (arteriography) findings (according to Scott and Bacon criteria) Results A total of 18 patients were included: 6 (33.3%) females and 12 (66.7%) males, mean age of 10.13±66.5 (49-83 years). The clinical characteristics of patients are listed in Table 1. The most common clinical presentation was skin involvement with palpable purpura and digital ulcers. Other common manifestations were multineuritis and systemic involvement. Heart, eyes, or pulmonary involvements secondary to RV were absent. Laboratory tests at diagnosis of RV, showed an increased of acute phase reactants and anemia. All patients had a positive rheumatoid factor, citrullinated antibodies were determined only in five (27.8%) cases, being positive in all of them.Histological confirmation was possible in 8 (44.4%) cases, in the other 10 (55.6%) cases the diagnosis was made with clinical or radiological findings. Most patients were treated with pulse steroids associated with other immunosuppressive drugs. Seven (38.9%) patients died. Three of them (16.7%) secondary to vasculitis, and 4 (22.2%) of other causes.The incidence of rheumatoid vasculitis has decreased considerably in the last decade. Just 4 cases were diagnosed during the last 10 years. Conclusions RV is a rare complication of RA. Cutaneous and neurological involvement is more common. It is more frequent in male smokers with seropositive and nodular RA. Histological diagnosis is difficult. Currently the incidence is decreasing, however mortality is still high. Disclosure of Interest None declared

Background Secondary amyloidosis (AAa) is a disorder caused by deposition of insoluble amyloid A fibrils in different tissues and organs. It is a rare and serious complication of rheumatic diseases including spondyloarthropathies. Objectives The aim of this study was to determine the clinical features, laboratory data, treatment and clinical outcome of patients with spondyloarthropathies who developed AAa. Methods Design retrospective (1984-2013). Hospital: academic tertiary hospital. Referral area: 850.000 inhabitants. We reviewed the medical records of 1125 patients with spondyloarthropathies: 509 (45%) psoriatic arthritis (PsA), 263 (23%) ankylosing spondylitis (AS), 128 (11.3%) spondylitis associated with inflammatory bowel diseases (IBD), 190 (16.8%) undifferentiated spondyloarthropathy and 35 (3.1%) reactive arthritis diagnosed at our centre. We selected patients who had a histological diagnosis of AAa. Results Twelve (1.06%) patients with AAa were recruited: 10 (83%) males and 2 (16.6%) females. Five (41,6%) AS, 3 (25%) PsA, 3 (25%) spondylitis associated with IBD and 1 (8%) reactive arthritis. Mean age at AAa diagnosis: 55.75 years (interval 71-33 years). Amyloid deposits were observed on rectal biopsy (5 cases), kidney biopsy (3 cases) and subcutaneous fat biopsy (2 cases). In two cases the diagnosis was made incidentally (bladder and gallbladder). The mean age at spondyloarthropathy diagnosis was 32 years and the mean disease duration was 23.2 years. The mean values of erythrocyte sedimentation rate and C-reactive protein, at diagnosis of AAa, were 58.71mm and 35.47 mg/L respectively. AAa was suspected in 8 patients because of nephrotic-range proteinuria (2 patients), acute renal failure (5 patients) and diarrhea (1 patient). HLA B27 was positive in 6 patients, negative in 2. Five patients were treated with infliximab, 4 of whom because amyloidosis. Four patients underwent hemodialysis for end-stage renal disease, one of them died because complications directly related to renal failure. Four patients died of sepsis. Conclusions The frequency of clinical apparent AAa in our patients was 1.06% (12 patients). There was a marked male predominance. Clinical AAa was diagnosed at a relatively late stage in spondyloarthropathies. The predominant clinical picture was nephrotic syndrome. Prognosis was ominous. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3143

Background Undifferentiated arthritis (UA) is defined as an inflammatory arthritis in which no definitive diagnosis can be made. The prognosis of patients with UA may vary from spontaneous remission, to severe defined inflammatory joint disease. Patients UA poses a challenging problem to the rheumatologist. It is important to identify patients who will develop a persistent and/or erosive disease because early treatment might offer an effective means to slow disease progression. Objectives To describe the outcome of patients with UA after 30 months of follow up. Methods Design retrospective (2006 - 2011) in an academic tertiary hospital with a reference area of 850,000 inhabitants. We reviewed the medical records of patients with “undifferentiated arthritis” from the database of rheumatology Department. We reviewed the pattern of involvement at the onset of the disease and final diagnosis in December 2013. Results A hundred and fifty four patients were included. The involvement, at the beginning of the disease was: 36 (23.3%) monoarticular, 71 (46.1%) oligoarticular and 47 (30.5%) polyarticular. During follow-up, it was observed that 30 (19.5%) patients went into remission spontaneously, 57 (64.9%) evolved to a defined inflammatory joint disease and 67 (43.5%) continued under the diagnosis of undifferentiated arthritis. Among those patients were a definite inflammatory joint disease was established: 38 (66.6%) continued follow up controls, 16 (28%) discontinued the follow-up and 3 (5.3%) were discharged. A progression to extended polyarthitis was observed in 3 patients with an oligoarticular pattern. Four patients with monoarthitis developed oligoarthritis. The knee was the most commonly involved joint (58.3%). Conclusions The most common pattern of joint involvement in UA is oligoarticular. Furthermore half of patients with UA went into remission. Patients with a monoarticular pattern had a greater chance of spontaneous remission compared with patients with oligo and polyarticular involvement. The frequency of follow up was also significantly higher in patients with definite inflammatory joint disease compared with patients with persistent UA (66.6% versus 47.7%). Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2933

Background In some rheumatic diseases low dosis of glucocorticoids (2-5 mg) are used for long periods of time. It is not clear if there is an inhibition of the adrenal axis when one of these patients experiences a stressful situation, such as an illness. This is particularly important in elderly patients, who are most vulnerable to hospitalization. Objectives Determine whether there is inhibition of adrenal axis in elderly patients under treatment with low dosis of corticosteroids. Methods Design: prospective. Type of center: University hospital with a referral area of 850,000 inhabitants. Nineteen patients with inflammatory rheumatic diseases (Elderly Onset Rheumatoid Arthritis and Polymyalgia Rheumatica) were studied: 7 women and 12 men, with a mean age of 77±6.84 years. We underwent stimulation test with synthetic ACTH 1 μg before the onset of oral glucocorticoid treatment and 6 months later. Methylprednisolone was the glucocorticoid used in all patients. The starting mean dose used is these patients was 9.26±2.68 mg, the dose accumulated in 6 months 972.6±248 mg, and the mean daily dose of 5.22±1.0 mg/day. Statistical methods: student t test, ANOVA and ROC curve. Results A good response was observed in all patients before before the onset of oral glucocorticoids (cortisol at 30 minutes ≥18 mg/dl). After 6 months of treatment the basal cortisol decreased from 18.5±5.9 to 11.95±5.9 (p=0.002) and the stimulated one from 28.96±5.8 to 17.95±5.98 (p Patients with an inadequate response had received a higher starting dose of glucocorticoids (8±2.8 versus 10.4±2.0, p=0.048) and also a higher mean daily dose (4.6±1.05 versus 5.7±0.7, p=0.018). Moreover, the accumulated dose and the mean daily dose were inversely correlated with the cortisol response. The ROC curve analysis at 6 months of treatment showed that the best cut off for predicting a poor response was a mean daily dose of 5.16 mg/day, with 70% sensitivity and 88.89% specificity (AUC =0.789, p=0.0065) and that a 100% of patients with insufficient response received a mean daily dose higher than 4.5mg/day. Conclusions A large percentage of elderly patients treated with low dosis of glucocorticoids showed adrenal axis inhibition after a few months of treatment. Thus, supplementation with higher dosis of glucocorticoids should be recommended to these patients in stressful situations. Acknowledgements To all the Biochemistry and Reumathology nurses. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4520

Background Autoantibodies against SS-A/Ro include two specificities (anti-Ro52 and anti-Ro60). These are directed against different antigens. Sera with reactivity against Ro52 are usually precipitin negative and cannot be detected by SS-A/Ro native based ELISAs. This fact has generated a bias to the detection of Ro60 when classifying SS-A/Ro positive patients. Currently the idea that anti-Ro52 and anti-Ro60 should be considered as independent markers in connective tissue diseases (CTD) is gaining ground. Objectives To correlate the detection of antibodies against Ro52 and/or Ro60 and the development of an organ specific clinical pattern in patients with CTD Methods Design retrospective (1999-2012). Type of center: University academic center with a referral area of 800.000 inhabitants (HUGTiP). Sera from patients with CTD from HUGTiP where tested for SS-A/Ro specificities by ELISA (Orgentec) and inmunoblot (Innolia). Medical records of all the patients with positivity for one of the specificities in at least one occasion were analyzed. In addition demographic, immunological and clinical data of the patients with systemic lupus erythematosus (SLE), Sjogren syndrome (SS), systemic sclerosis (SSc) or poly-dermatomyositis (PM-DM) were recorded. Results Data from 347 patients (299 women and 48 men) with positive serum were collected. Mean follow up 7.1 year (0-12.8 years). Of those, 151 presented reactivity only against Ro52 (Ro52+), 34 against Ro60 (Ro60+) and 162 against bothspecificities (Ro52+Ro60+). The associated diagnoses were: SLE (n=99), SS (n=57), PM-DM (n=15), SSc (n=20), undifferentiated connective tissue diseases (n=12), inflammatory arthropathy (n=20; rheumatoid arthritis=9) and liver diseases (n=34; VHC=21 and autoimmune liver diseases=13). Finally, 30 patients wereunclassified. Ro 52+ patients included SLE (16%, n=24), SS (11%, n=17), SSc (12%, n=18) and PM-DM (10%, n=15). While Ro52+Ro60+ included mainly SLE (37%, n=60) and SS (27%, n=43) but also SSc (2%, n=3) and PM-DM (0.5%, n=1). Finally Ro60+ included only SLE (44%, n=15) and SS (6%, n=2). Interestingly enough: 18% (n=26) of the Ro52+patients and 8% (n=13) of the Ro52+Ro60+ patients presented lung involvement, while none was detected in the Ro60+ group. Ro52+ patients showed more involvement of the lung than Ro60+ patients (p=0.003). Furthermore Ro52+ and Ro60+ groups also showed differences in the frequency of presence of sicca syndrome (p=0.024) and Raynaud phenomenon (p=0.016). No differences were founded in the frequency of involvement of heart, renal, cutaneous, and hematological systems or in cancer. Conclusions Antibodies against Ro60 are associated to SLE and SS while Ro52 are present in a heterogeneous group of diseases. Our data suggest that Ro52 is a marker of systemic involvement. Ro52 patients have more involvement of the lung, sicca syndrome and Raynaud phenomena. Disclosure of Interest None Declared

Background Still’s disease is a rare systemic entity of unknown etiology,characterized by fever peaks with evanescent rash, arthritis and/or joint pain that is associated with odynophagia, lymphadenopathy and hepatosplenomegaly. Diagnosis is difficult and exclusion. Treatment has varied over time. Systemic glucocorticoidsare the first choice, although biological drugs are an alternative for refractory cases. Objectives Describe the clinical characteristics and evolution of a series of patients diagnosed with Still’s disease who have followed biological treatment. Methods Retrospective (1978-2011). UniversityHospital with a referal area of 800,000 inhabitants. We reviewed the medical records of patients from the database section of Rheumatology.Inclusion criteria: patients with Still’ disease following Yamaguchi critera who were treated with biological drugs. Results Seven patientswere selected: 5 women (71.5%) and 2 men (28.5%).The mean age at diagnosis was 30.2 (16-58).All hadsore throat,fever and allbut onerash.All hadpolyarthralgia. Six patients (85.7%) polyarthritis and one oligoarthritis.Four patients (57.1%) had splenomegaly, lymphadenopathy 2 of them (28.5%). Two patients did not have any of these clinical signs.Serositiswas foundonlyin one patient. Inlaboratory data yielded: leukocytosis with neutrophilia in 2 patients (28.5%), anemia (hb ≤12 g/dL in 3 patients (42.9%). Ferritinwas elevatedin two patients. The ESR was elevated in 4 cases (57.4%), with a mean of 45±39.53 mm in the first hour. The CRP was elevated in six patients (85.5%) with an average of 27.5 mg/L. Mean follow-up: 70 months. The form of evolution of the disease was polycyclic in 4 patients and monocyclic in three. Biological treatment was: anakinra in 5 patients (71.5%), etanercept, 2 patients (28.5%), tocilizumab, two patients (28.5%).In addition, one patient was refractory to all biologicals(infliximab, rituximab, anakinra,tocilizumab, abatacept). Three patients (60%) treated with anakinra achieved complete remission. The other two patients without remission, were treated with tocilizumab with a good response in one case. The remaining patientwas treated well with infliximab, rituximab, anakinra and tocilizumab. All treatments weerretired because of serious side effects or ineffectiveness. This patient is currently treated with abatacept with good response although is not achieving complete remission. The 2 patients treated with etanercept achieved complete remission. Conclusions Biological therapy as treatment for refractory Still’s disease was effective in most cases. Anakinra was the drug most widely used and more than half of patients who were treated with it, achieved complete remission. Disclosure of Interest None Declared

Background Assays that detect anti-citrullinated peptides antibodies (ACPA) are considered to be more specific than rheumatoid factor in the diagnosis of rheumatoid arthritis (RA). Several tests have been developed using different antigens: first, second and third-generation cyclic-ACPA (CCP1, CCP2, CCP3) and modified citrullinated vimentin (MCV). Objectives To investigate anti-CCP3 in a group of patients positive citrullinated vimentin antibodies (MCVA). Methods The retrospective study was done at the university hospital with a reference population of 800,000. Atotal of 259 patients positive for IgG MCV antibodies (by ELISA) attending the outpatient rheumatology clinic were tested for anti-CCP3 (by ELISA). From the total, 182 (70.3%) of them had a rheumatic disease: RA in 121 (66.5%) and other: elderly-onset arthritis, non-filiated arthritis, connective, vasculitis, Still’s disease, espondiloarthritis, microcrystalline arthritis, polymyalgia rheumatica and sarcoidosis, in 61 (33.5%). There are 77 (29.7%) patients with other conditions (non rheumatic disease) positive for MCVA were also tested for anti-CCP3. Results From the 121 RA patients, 106 (87.6%) were positive for anti-CCP3. In contrast, only 15 (24.6%) of the 61 patients without RA and only 4 (5.2%) of the 77 MCVA positive patients with no rheumatic disease associated were CCP3 positive. Interestingly, within the group no RA, of the 13 patients with anti-CCP3 values >60 U/ml, 6 (46.2%) were patients with palindromic rheumatism and two of them had developed RA. Specificity of anti-CCP3 for RA as compared to other rheumatic disease was 76.7%, that raised to 86.9% when comparing RA versus to non-RA (with or without another rheumatic disease). Positive and negative predictive values of anti-CCP3 for RA were 85.5% and 88.8%, respectively whereas positive predictive values for anti-MCV was 39.1%. Conclusions Anti-CCP3 antibodies show a higher specificity for RA when compared to MCVA with a better positive predictive values, a crucial feature for a test in use for clinical practice. Disclosure of Interest None Declared

Objectives To describe the clinical characteristics, treatment and outcome of patients diagnosed with pyogenic septic arthritis. Methods Design: retrospective (1984-2012). Location: University hospital. Referial area: 800,000 inhabitants. The medical records of patients with pyogenic arthritis were reviewed. Inclusion criteria: isolation of bacteria in joint fluid or blood. Patients with soft tissue infection, prosthetic, fungal and mycobacterial septic arthritis were excluded. Results One hundred one patients were selected: 66 males and 35 females. Mean age: 54.5 ± 21.2 years. The following risk factors were identified: alcoholism (24), cirrhosis (12), diabetes mellitus (18), chronic renal failure (17), neutropenia (6), immunosuppression (10), HIV (10), AIDS (5), parenteral drug addiction (12), cancer (6), RA (4) and microcrystalline arthritis (17). Seventeen patients had undergone joint manipulation prior to the onset of the infection: 9 arthrocentesis with corticosteroids injection, 6 arthrocentesis and 2 arthroscopies. The pattern of join involvement was monoarticular in 72 patients (71.3%): knee 38 (36.8%), and shoulder and ankle 8 (8%) respectively. Polyarticular involvement was found in 29 patients (28.7%). Fifty nine patients 58.4% had fever. Cellulitis was observed in 17 cases (17%). The mean time between onset of symptoms and diagnosis was 7.9 ± 8.2 days. Mean hospital stay was 30.4 ± 28 days. Blood cultures were positive in 40 cases (39.7%) and in 85% of them the same microorganism was isolated in joint fluid. Septic arthritis was caused by gram positive in 79%, gram negative 19% and 2% were polymicrobial. The most common were: S. aureus methicillin sensitive (45), S. aureus methicillin resistant (MRSA in 5 cases since 2008), S. agalactiae (6), S. pyogenes (3), S. pneumoniae (9), E.Coli (9), P.aeuriginosa (3), Enterobacter cloacae (2) and Salmonella (2). Acute phase reactants were increased: ESR: 89.5 ± 29.6 mm/1sth and C-reactive protein 162 ± 122 mg/dl. The mean leukocyte count of joint fluid was 65,602 ± 62477/mm 3 . Synovial glucose was decreased in 50% of patients. Mean duration of intravenous antibiotic therapy: 3 weeks. Thirty-four patients (33.6%) required surgical treatment. Three patients required a second arthrotomy. Complications were: septic shock (20), pneumonia (6), reflex sympathetic dystrophy (2), osteonecrosis (2), endocarditis (3), respiratory distress (1). Most of the cases evolved favorably. Fifteen cases resulted in death (15%): 8 cases had monoarticular involvement and 7, polyarticular involvement. The causative organisms were: S. Aureus (10 cases), MRSA (3 cases), Pneumococcal (1 case) and polymicrobial (1 case of S.aureus more E.Coli). Conclusions S. aureus is the most common pathogen isolated. Furthermore MARSA is an emerging microorganism. Hematogenous spread and polyarticular involvement are poor prognostic factors. Prolonged antibiotic therapy and surgical debridement are essential for proper healing. Disclosure of Interest None Declared

Background Heart block in the young is uncommon and sometimes the etiology is not found. Several inflammatory rheumatic diseases can cause conduction disturbances. Some of them are well described, such as in patients with ankylosing spondylitis, but others are controversial. Ro autoantibodies have been traditionally associated with the development of neonatal lupus and congenital heart block. Recent research has demonstrated their physiopathological implication. Some investigators have tried to demonstrate the relationship between these autoantibodies and electrocardiographic abnormalities in adult patients with controversial results. Objectives To determine whether atrioventricular block (AVB) of unknown cause in young patients may be associated with an inflammatory rheumatism. Methods Retrospective observational study (1973-2011) at a university hospital with a referral area of 800000 inhabitants. The medical records of patients with pacemakers were reviewed from cardiology’s database: a total of 3359 patients. Patients under fifties with a heart block of unknown cause were selected: 24 patients. One was dead at the time of the study, and 3 refused to participate. The 20 remaining patients underwent an immunological study with antinuclear antibodies (AAN in HEp2 substrate) and extractable nuclear antigens (ENA) by immunoassay and immunoblot. A clinical interview was performed by a rheumatologist looking for signs and symptoms of inflammatory rheumatism. Results Twenty patients were included: 7 men (35%) and 13 women (65%). Mean age when they were reviewed was: 51 years ± 12 years (range: 28-70). Mean age at the time of pacemaker implantation was 37.5 ± 10 years (range: 17-49). The implantation causes were: complete AVB 14 patients (70%), advanced AVB 3 (15%), Wenckebach type 1 AVB (5%) and unknown AVB in 2 cases. Two patients had family history of autoimmune diseases: 1 rheumatoid arthritis and 1 autoimmune thyroiditis. A positive Ro52 patient without connective tissue disease and a Ro 60 positive patient diagnosed with systemic lupus erythematous were found; no other autoantibody was present. Another patient was diagnosed of ankylosing spondylitis (HLA B27 positive). The diagnosis of systemic lupus erythematous and ankylosing spondylitis were previous to the heart block. No signs or symptoms of inflammatory rheumatism were found in the other patients. The Schirmer test was abnormal in 5 (20%) patients. The 2 patients with systemic lupus erythematous and ankylosing spondylitis had sicca syndrome secondary to their underlying diseases. Conclusions Fifteen percent of patients had features of inflammatory rheumatic diseases: in 2 cases heart block occurred in a patient diagnosed with systemic lupus erythematous and another with ankylosing spondylitis. A third case with positive Ro52 antibodies was detected in a woman without connective tissue disease. Family history of autoimmune diseases was found in 2 patients. Anti Ro antibodies might be related to heart block in the young. It is recommended to purpose a clinical evaluation of the patients by a rheumatologist and an immunological study in order to clarify the origin of the heart block and to unmask other underlying pathologies. References Disclosure of Interest: None Declared

Background The association of the SAPHO syndrome and inflammatory bowel disease (IBD) was first reported in 1992. To date, only case reports and short series have been published. Objectives To report three new cases and systematically review the literature on this association. Methods All patients with concomitant diagnosis of SAPHO syndrome and IBD were identified from the databases of the Rheumatology and Gastroenterology departments of our institution, which has a reference area of 800000 inhabitants. In addition, we systematically searched for published full articles in Medlars Online International Literature (MEDLINE) via PubMed. Relevant information of each positive match was collected and all authors were contacted for additional clinical data. Results Three patients sharing both SAPHO syndrome and IBD were identified among the 62 patients with SAPHO syndrome (4.8% of the SAPHO cohort) and among 1,309 patients with IBD (0.2% of the IBD cohort) from our hospital database. After a systematic review, others 36 cases with concomitant diagnosis of IBD and SAPHO syndrome or its variant chronic recurrent multifocal osteomyelitis (CRMO) were identified. There was a female predominance (64%) and an early age of onset of both diseases (24 years for SAPHO syndrome and 18 years for IBD). SAPHO diagnosis preceded IBD diagnosis in 55% of cases, being simultaneous or subsequent in the rest. A high proportion of patients presented Crohn’s disease (69%) with colonic involvement. The most frequent osteoarticular locations were peripheral joints (61%); anterior chest wall (56%), sacroiliac joint (20%), y spine (18%). Approximately 41% of cases developed typical SAPHO skin manifestations, being palmoplantar pustolosis the most common. The most common treatment for IBD of the subgroup of cases published after year 2000 were corticosteroids (68%), aminosalicylates (52%), immunossupresors (37%), anti-TNF (16%); and for SAPHO syndrome NAIDs (63%), corticosteroids (37%); aminosalicylates (31%), immunossupresors (21%), pamidronate (16%) y anti-TNF (16%). Conclusions SAPHO syndrome seems to precede IBD. It is more frequent in females and at early ages. Crohn’s disease is more associated to SAPHO than ulcerative colitis. Interestingly enough colic involvement is more frequent. Both diseases respond well to the same treatments but NAIDs should be avoided because their potential risk of triggering a flare of IBD. Disclosure of Interest None Declared

Background Adult Onset Still’s disease (AOSD) is a rare systemic disease of unknown etiology,characterized by fever peaks with a evanescent rash, arthritis and/or arthralgia that is associated with odynophagia, lymphadenopathy and hepatosplenomegaly. Laboratory test usually present with leukocytosis, neutrophilia, anemia and an increased in acute phase reactants. There is no pathognomonic laboratory test. Diagnosis is difficult and exclusion of other diseases is requered. Objectives To describe the clinical characteristics, treatment and outcome of a series of patients diagnosed with adult Still’s disease. Methods Retrospective (1978-2011). UniversityHospital with a referal area of 800,000 inhabitants.We reviewed the medical records of patients from the database service of Rheumatology. Inclusion criteria: Yamaguchi criteria. Results Thirty one patients were diagnosed: 9 men (30%) and 21 women (70%). The mean age at diagnosis was 39.9 years (16-68). All had fever associated with rash, except for 3 patients who were enrolled without a rash. The odynophagia was presented in all cases except 1. Polyarticular pattern predominated (22 patients, 73.3%) compared to oligoarticular (3 patients, 9.7%); in 5 patients was not found arthritis, however, arthralgia were seen in 96.7% of cases. Twelve patients had lymphadenopathies and eleven, splenomegaly. Seven patients had both clinical signs. Serositis was uncommon, affecting only 3 patients. Laboratory findings were as followed: leukocytosis with neutrophilia (22 patients, 73.3%), anemia with hemoglobin ≤12 g/dl (15 patients, 50%), with mean hemoglobin of 11.5g/dl, transaminitis (9 patients, 1%), high ferritin with an average of 6614 ng/ml in 19 patients (63.3%). The ESR was determined in 29 patients and was founded elevated in 24 (80%), with a mean of 77.4±39.8 mm in the first hour. C Reactive Protein was determinedin 26 cases, being elevated in 21 patients (70%).Joint radiographswere performed according to articular involvement and remained normal in 23 patients (76.7%). The treatment was: aspirin and/or NSAIDs (90%), corticosteroids (76%), other disease-modifying drugs, 15 patients (76.7%); biological drugs, 6 patients (20%). Mean follow-up: 88 months. The form of evolution of the disease was polycyclic in 15 patients (50%) and monocyclic on the other half of patients. Remission during follow-up was presented in 27 patients (93.1%). Conclusions The clinical and laboratory characteristicsof this series, did not differ from those reported by other authors. All in all Adult Onset Still’s disease responded to treatment. Biological drugs was required in one third of patients. Disclosure of Interest None Declared

Background IFN-γ release assays are useful methods for diagnosing LTBI (latent tuberculosis infection). It allow us to detect: a) false negative TST in anergic subjects, b) false positives in BCG-vaccinated patients and c) NTM (non-tuberculous mycobacterias) previously sensitized individuals. All in all, these tests contribute to detect additional cases of LTBI. Objectives To establish the usefulness of blood interferon-γ (IFN-γ) release assays in patients with inflammatory rheumatic diseases scheduled for anti-TNF-α treatment and at the follow up. Methods Prospective study including rheumatic patients starting an anti-TNF-α agent. All patients underwent TST (two step), a chest radiograph, QuantiFERON GOLD in tube (QFN-G-IT), and T-SPOT.TB. Both tests were repeated after a year of anti-TNF treatment in 21 patients. As control group, 35 adult individuals were included. Concordance were analyzed by Cohen’s kappa test. Results We included 53 patients (18 male/35 female) candidates for anti-TNF-α (18 rheumatoid arthritis, 13 ankylosing spondylitis, 9 psoriatic arthritis and 13 miscellanea). Mean age was 49±13 years and mean disease evolution was 8.8±8 years. Twenty-four out of 53 patients (45.3%) were receiving systemic steroids, mean daily dose 9.1±11.9 mg/day. BCG vaccination status was documented in 3 patients, 2 referred history suggestive of TB disease and other 3 patients had contact with a confirmed TB case in the past. The results of our study are summarized in Table 1. The differences in the results between the IFN-γ tests were not significant ( p= 0.675). Interestingly enough, neither T-SPOT.TB nor QFN-G-IT were significant in comparison to TST results ( p= 0.344 and p= 0.727, respectively). Overall agreement between TST and T-SPOT.TB and QFN-G-IT was 77.35% (k=0.33; and k=0.40, respectively), and between both in vitro tests was 83.01% (k=0.57) was observed. Three patients with positive TST and negative T-SPOT.TB and QFN-G-IT, was positive on ELISPOT after stimulation with NTM sensitins. Positive TST, T-SPOT.TB and QFN-G-IT results were not affected by the immunosuppressive therapies. We found 4 conversions (1 patient convert T-SPOT and QFN, and 3 patients convert only T-POT) out of 21 cases evaluated after a year under anti-TNF-α agents. We also observed 2 reversions, one in a patient who had undergone prophylactic treatment for tuberculosis. Conclusions In those patients with a high risk of developing active TB, the combined use of TST and IFN-γ may be recommended to increase the overall number of LTBI diagnosis. Reversion is described in subjects who have made prophylaxis. More studies are needed to recommend prophylaxis in conversions. Disclosure of Interest None Declared