Search

The objective of the study is to investigate the clinical characteristics and long-term prognosis including flares and organ damage in patients with giant cell arteritis (GCA) from a tertiary referral centre and compare these features in different subgroups. In this retrospective observational study, patients with GCA who were followed up in our vasculitis clinic between 1998 and 2018 were evaluated by a predefined protocol. Patients with and without cranial symptoms were compared for clinical and laboratory features, flares and permanent damage findings. Vasculitis Damage Index and Large Vessel Vasculitis Index of Damage were used for damage assessment. Records of 89 patients (median follow-up time 46 months) were analysed; mean time to diagnosis after initial symptom was longer in patients with acute vision loss (11 ± 4 vs. 4.8 ± 1.1 months p = 0.002). EGG (n = 19) was younger (63 ± 2 vs. 69 ± 1 years old p = 0.01); had higher mean CRP (141.8 ± 107.3 vs. 76.6 ± 67.9 mg/dL p = 0.023) and ESR (120.8 ± 25.1 vs. 99.3 ± 24.3 mm/h p = 0.004) at diagnosis. PET-CT detected large vessel vasculitis in 42/48 (87.5%) cases of the entire cohort. Thirty-one patients had flares and proportion of flared patients was significantly higher in patients with cranial symptoms. At least one damage item (DI) was present in 54 (60.7%) patients. The development of damage was found to be associated with flares. Evaluation of our cohort revealed the importance of early diagnosis for prevention of vision loss in GCA. Patients without cranial symptoms were younger, present with higher inflammatory response and for these, PET-CT was the main diagnostic tool. Relapse rate was higher in patients with cranial symptoms. Flares and accompanying corticosteroid treatment may contribute to organ damage in GCA.

Objective.Major salivary gland ultrasonography (SGUS) is a widely used imaging technique to evaluate salivary gland involvement in primary Sjögren syndrome (pSS). The aim of this study was to evaluate the relationship between SGUS, salivary flow rate (SFR) as an objective measure of the gland function, and oral health-related quality of life (OHRQOL) as a patient-reported outcome measure (PROM) in a pSS cohort.Methods.Sixty-six patients with pSS were examined by SGUS according to Hocevar and Milic scoring systems. Patients with inhomogeneity/hypoechoic areas with scores ≥ 2 in parotid and submandibular glands were classified separately as “severe glandular involvement.” Further, oral health, SFR, and Oral Health Impact Profile-14 (OHIP-14) for OHRQOL were assessed.ResultsBoth total Hocevar and Milic scores were higher in 21 pSS patients with low unstimulated whole salivary flow rate (U-WSFR) than 45 pSS patients without low U-WSFR (P = 0.001 and P < 0.0001, respectively). Increased scores of homogeneity, hypoechoic areas and glandular border visibility were observed in patients with low U-WSFR (P < 0.05). Among these variables, homogeneity score was found to be an independent risk factor for low U-WSFR in pSS according to logistic regression analysis (OR 1.586, P = 0.001). Moreover, a higher OHIP-14 score was observed in severe parotid involvement compared to nonsevere cases (23.26 ± 21.19 vs 8.32 ± 13.82, P = 0.004).Conclusion.High Milic and Hocevar SGUS scores are associated with reduced SFR and poor OHRQOL as a PROM. The inhomogeneity component of the SGUS score is associated with low U-WSFR and is an indicator of severely affected gland function.

Purpose: pulmonary involvement is common in adults with scleroderma. The effect of concomitant obstructive sleep apnea (OSA) on risk for pulmonary hypertension in scleroderma is unknown. An enlarged main pulmonary artery diameter (mPAD) derived from chest computer tomography (CT) is a useful predictor of pulmonary hypertension. We addressed the effect of OSA on pulmonary involvement and enlarged mPAD in adults with scleroderma. Methods: all participants underwent pulmonary function testing, carbon monoxide diffusion capacity, chest CT, and overnight sleep recording with home sleep apnea testing. OSA diagnosis was based on an apnea-hypopnea index (AHI) >= 15/h. Oxygen desaturation index (ODI) was also recorded. Scleroderma involvement of the lungs was defined as the Warrick score >= 7 based on the CT findings. Enlarged mPAD was defined as an mPAD >= 29 mm in men and >= 27 mm in women. Results: after exclusions, 62 patients (58 women) were included. OSA was found among 20 (32%), 17/42 (38%) in the limited cutaneous type, and 3/20 (15%) in the diffuse cutaneous type (p = 0.08). Scleroderma involvement of the lungs was observed in 40 participants (65% in OSA vs 64% in no-OSA; n.s.). Enlarged mPAD was measured in 16 participants, 10 of 20 (50%) in the OSA group and 6 of 17 (14%) in the no-OSA group (p = 0.003). OSA was associated with enlarged mPAD (odds ratio 4.7, 95% confidence interval 1.1-20.9; p = 0.042) independent of age, body mass index, and pulmonary involvement. There was a linear relationship between mPAD and AHI (r = 0.37; p = 0.003) as well as ODI (r = 0.41; p < 0.001). Conclusions: in this cohort, OSA was associated with risk for pulmonary hypertension independent of pulmonary involvement. These findings suggest that assessing the effect of therapy for concomitant OSA in patients with scleroderma is warranted., University of Gothenburg

Background:The negative impact of COVID-19 in patients with ANCA associated vasculitis (AAV) and patients on rituximab (RTX) treatment have been reported (1). Risk factors for severe course of COVID-19 and increased mortality in these patients are unclear.Objectives:To evaluate the course of COVID-19 in our AAV cohort and identifying risk factors for mortality.Methods:Patients with AAV who were classified according to CHCC and whose scheduled last visit were after December 2019 were screened and evaluated for COVID-19 either by phone call or in the clinic. Records of patients with a history of hospital admission due to COVID-19 were evaluated. Cumulative clinical findings and treatment history were noted. Hypogammaglobulinemia (hIgG) was defined as IgG level below 700 mg/dl. All inpatients with a diagnosis of COVID-19 were screened for hIgG and IVIG was administered if necessary.Results:Eighty-nine patients (47.2% female, mean age 56 + 12.5 (28-81)) were included into the study. The diagnosis was GPA in 56 (62.9%) and MPA in 33 (37.1%) patients. Mean follow up time was 91 + 53.4 (26-272) months. Anti-PR3 and anti-MPO were positive in 46 (51.7%) and 32 (35.9%) patients, respectively. Lower respiratory tract (LRT) involvement was present in 72 (80.9%) and 10 patients had a history of diffuse alveolar haemorrhage (DAH). Sixty-one patients (68.2%) had a history of rapidly progressive glomerulonephritis (RPGN) and 21 (23.6%) had peripheral nervous system (PNS) involvement.Fifteen (16.9%) patients had COVID-19; 14 of them were PCR positive, one patient had symptoms and thorax CT findings compatible with COVID-19. Pulmonary infiltrates were observed in 13 patients (86.7%); 9 (60%) had severe pneumonia. Twelve patients (85.7%) were hospitalized, 6 patients (42.9%) needed ICU admission and 5 patients (35.7%) died. Tocilizumab and anakinra for hyperinflammation during COVID-19 were used in 1 (6.7%) and 4 (26.7%) patients, respectively.Four out of five deceased patients (3 on RTX treatment, 1 with renal transplant) were in remission at the time of COVID-19. COVID-19 was detected in a patient with disease flare and DAH, during treatment with high dose steroids and plasmapheresis. hIgG was detected in all deceased patients from COVID-19 during hospital admission (mean IgG: 495±113.2 mg/dL).Symptomatic COVID-19 was more frequent in patients with a history of DAH, RPGN and hIgG. hIgG during the follow-up was significantly associated with COVID-19 in multivariable analysis (p=0.01, OR=20,6 %95 CI (2-210). Comparison of patients who died of COVID-19 and survived showed that female sex, PNS involvement and hIgG during the clinical course and hospital admission were risk factors for increased mortality (Table 1). Age, smoking, treatments, history of flares or serious infections, remission status and chronic renal insufficiency did not differ between groups.Conclusion:The frequency and mortality from COVID-19 is found to be high in our AAV cohort compared to previous reports (1). Patients with serious lung or renal involvement are prone to symptomatic COVID-19. Previously reported severe outcomes on RTX therapy might be related to consequent hIgG. High dose IVIG treatment may not be sufficient in improving survival in AAV patients with severe COVID-19 and hIgG.References:[1]Severity of COVID-19 and survival in patients with rheumatic and inflammatory diseases: data from the French RMD COVID-19 cohort of 694 patients. 2020:annrheumdis-2020-218310.Table 1.Comparison of risk factors for CI and mortality in patients with AAVCOVID-19 (n=15)Non-infected (n=74)pORDeath (n=5)Survive (n=10)p2OR2Age53.4±11.956.6±12.6NS51.2±12.654.6±12.1NSSex (female)635NS420.03614 (0.9-207)LRT Involvement1458NS59NSDAH460.0384.1 (1-16.9)13NSRPGN15460.0048.5 (1-68.4)57NSPNS involvement318NS300.0059 (1.4 - 57)RTX treatment1033NS37NShIgG in outpatient visits670.026.3 (1.8-23.3)420.0216(1.5-234)hIgG during hospitalization due to CI----540.0252.5 (1.2-5.4)Flares≥1725NS43NSChronic Renal Insufficiency722NS43NSDisclosure of Interests:None declared

We aim to investigate the relationship between pulmonary function and imaging parameters with symptom-related patient-reported outcome measures (PROs). We included 65 patients of rheumatoid arthritis (RA) and connective tissue disease (CTD) with and without interstitial lung disease (ILD) into this cross-sectional study. We evaluated the relationship between FVC, DLco, and PROs and compared to HRCT findings. PROs included visual analogue scale for breathing, modified Borg scale, medical research council dyspnea scale, St. George’s respiratory questionnaire (SGRQ), Leicester cough questionnaire, and Short Form 36 quality of life (SF-36 QoL). The mean age was 57.4 ± 9.7 and 61.9% (39/65) of patients had an established ILD. In RA-ILD group, SGRQ score was higher (p < 0.001) and SF-36 physical functioning score was lower (p = 0.02) than CTD-ILD group. In RA group, there was a significant correlation between FVC and SF-36 role functioning/physical score (r = 0.724, p = 0.012). In CTD group, SF-36 general health score was correlated with both FVC (r = 0.441, p = 0.045) and DLco (r = 0.485, p = 0.035), and also SF-36 physical functioning score was correlated with FVC (r = 0.441, p = 0.040). PROs were found to be similar between ILD and non-ILD patients. SF-36 QoL total and SGRQ outcomes were worse in non-ILD group. We concluded that PROs could be used to evaluate health-related quality of life (HRQoL) in RA- or CTD-related ILD. The physical health determinants of HRQoL are measurably worse in RA-ILD patients than in CTD patients. But, PROs may not be very helpful in differentiating patients with cough and/or shortness of breath due to ILD or non-ILD causes in RA/CTD. • HRQoL may be affected differently among specific subtypes of ILD. • PROs can be used to evaluate dyspnea and function of patients with RA- or CTD-related ILD but are not distinguished from patients with cough and/or shortness of breath due to non-ILD causes in RA/CTD.

Background:Infection is a remarkable cause of morbidity and mortality in patients with SLE.Objectives:We aimed to determine the clinical course of COVID-19 infection in our patients with SLE and the factors affecting this courseMethods:SLE patients (2012 SLICC criteria) diagnosed with COVID-19 infection by a positive PCR test and/or typical findings of lung involvement in CT (computed tomography) imaging were included. Data regarding cumulative clinical and laboratory characteristics, histopathology results, autoantibody profiles, immunsuppressives and damage (SLICC damage index/SDI)) were retrieved from the existing database and revised. SLE Disease Activity Index (SLEDAI-2K) was determined at the time of infection.Results:Sixteen SLE patients with COVID-19 infection were identified. Most (87.5%) of these patients were female. Seventy % (n=11) had lupus nephritis. Twenty-five % had thrombotic antiphospholipid syndrome.PCR was positive in 70% (n=11) of the patients. Pulmonary parenchymal findings compatible with COVID-19 were observed in 56% (n=9) of those patients. Regarding complaints upon admission, 50% (n=8) had fever, 44% (n=7) cough, 44% (n=7) dyspnea, 19% (n=3) myalgia, 12.5% (n=2) headache, 12.5% (n=2) nausea /vomiting, 6% (n=1) diarrhea, and 6 % (n=1) had anosmia. Eight patients were hospitalized. Six of these patients needed oxygen therapy via nasal cannula. None needed a follow-up in the intensive care unit. The mean hospitalization duration was 14 ± 5 (8-25) days.Regarding disease activity at the time of infection, 9 had inactive disease with a SLEDAI-2K score of 0 whilst in 5 patients SLEDA-2K score was ≥4. The mean SLEDAI-2K score at the time of infection was 1.7 ± 2.3 (0-6). System/organwise, 1 patient with chronic thrombocytopenia presented with a worsening platelet count accompanied by serologic activity. This patient was a non-adherent to treatment who had stopped taking mycophenolic acid months before COVID19. Three patients 2 of whom had proliferative nephritis experienced nephritic flares.1 patient who had a history of cutaneous lupus and was in remission presented with oral ulcer, leukopenia and hypocomplementemia during infection. Of 16 patients, 7 had system damage at the time of infection. The mean SDI score of the patients was 1.4±1.8. Comparison of patients with and without damage revealed no significant differences in disease activity, symptoms associated with COVID, in the need for hospitalization, hospitalization duration, and the requirement for oxygen therapy. However,CT findings compatible with COVID19, were more common in patients with damage (87% vs.33%,p=0.04) and their mean CRP levels were higher at diagnosis (65 ± 47 vs.22 ± 48 mg/l;p=0.032).All patients received similar treatment for COVID-19 except active patients who required high dose steroids (2 with active renal, 1 with thrombocytopenia and 1 with oral ulcer, leukopenia and hypocomplementemia).The patient with thrombocytopenia also received intravenous immunoglobulin and 1 with cutaneous active disease received tocilizumab as she developed macrophage activation syndrome. Six patients (37.5%) had received rituximab (RTX) in the last 6 months before COVID. No significant difference, in terms of hospitalization and need for oxygen therapy due to COVID19 was found between patients who had received RTX vs who had not. No hypogammaglobulinemia was detected in patients who received RTX despite lower levels of IgG (998 ± 184 vs 1481± 51 mg/dl, p=0.02)Conclusion:Although half of the patients in our series of COVID19 infected SLE patients required hospitalization, there were no mortalities. More patients with damage (none pulmonary) displayed CT findings compatible with COVID19 and further follow up will reveal whether they will suffer from fibrotic lung disease. Patients can experience disease flares during COVID. But it is also important to consider that some manifestations such as thrombocytopenia may also be a sign of severe infection. Immunosupressive agents may not have a negative impact on the course of infection.*the first two authors contributed equallyDisclosure of Interests:None declared.

Background:COVID-19 runs a variable course resulting in acute respiratory distress syndrome and death in a subset of patients. The entry of SARS-CoV-2 into the cell stimulates innate immunity including NLRP3 inflammasome and lead to development of adaptive immunity later. Hyperinflammatory response with the release of proinflammatory cytokines including IL-1β and IL-6 results in cytokine storm in some patients with a worse outcome. Colchicine acts on NLRP3 inflammasome and inhibits and IL-1 mediated inflammatory attacks in gout and familial Mediterranean fever (FMF) patients. Patients with inadequate response to colchicine may benefit from anti-IL-1 biologic agents such as anakinra and canakinumab. Recently, favourable effects of anakinra have been observed in COVID-19 patients with findings of cytokine storm.Objectives:We aimed to evaluate the impact of COVID-19 among refractory FMF patients followed-up in tertiary referral with the treatment of biologic agents and also document the course of COVID-19 in these patients.Methods:We searched out database of FMF patients to identify those using biologic agents (anti-IL-1, anti-IL-6 or anti-TNF) for colchicine-refractory FMF. We interviewed the patients using a standard questionnaire by phone call for symptomatic COVID-19 and evaluated those patients who described findings of COVID-19 further by their hospital records or inviting them to the hospital for additional investigations.Results:We identified 183 patients and contacted 106 of them by phone in May-October 2020. A history of symptomatic COVID-19 was documented in 7 FMF patients who were on a biologic agent. Six were on anti-IL-1 and one was on anti-TNF, and one of the patients was not taking his biologic agents for 1 year. All of 7 patients had a favourable outcome. All but 1 patient followed at home and none of them developed findings of cytokine storm, thromboembolism and secondary bacterial infection. Hospitalized patient did not require intensive care unit (ICU) support or mechanical ventilation, and he was not given additional anti-inflammatory medications.Conclusion:This series of refractory FMF patients with potentially higher inflammatory characteristics showed COVID-19 did not result in a worse outcome in those patients during the first phase of the pandemic, and none developed findings of cytokine storm. Observations in these patients supports further that biologic agents blocking IL-1 and possibly TNF may contribute to the uneventful course of COVID-19 by preventing the development of hyperinflammatory response. Data collection from a larger group of patients, especially those with amyloidosis, will clarify the protective effects of colchicine and contribution of anti-IL-1 treatments on the favourable disease course during the second phase of the pandemic.Patient 1Patient 2Patient 3Patient 4Patient 5Patient 6Patient 7Age (years)45483953323731MEFV variantsUnknownM694V/M680IUnknownM694V/ M694VM694V/ M694VM694V/ M694VM694V/ M694VAmyloidosisNoNoNoNoNoNoNoBiologic agentsAnakinra100 mg/dayNot takenfor 1 yearAdalimu-mabCanakinumab150 mg/monthAnakinra100 mg/dayCanakinumab150 mg/monthAnakinra100 mg/dayPrednisone (mg/day)5NoNoNoNoNoNoColchicine(mg/day)21,51,51,51,52,02,0RT-PCR positivityYesYesYesYesYesYesYesChest CT signsYesYesNot doneNot doneNot doneNot doneNot doneHospitalisationNoNoNoYesNoNoNoAntiviral therapyOseltamivirOseltamivirNoFavipravirFavipravirFavipravirFavipravirHCQ useYesYesYesYesNoNoNoNew FMF attackduring COVID-19NoNoNoNoNoNoNoDisclosure of Interests:None declared

Background:Positron emission tomography (PET/CT) has gained importance in the diagnosis and assessment of large vessel vasculitis (LVV) recently.Objectives:We aimed to investigate the diagnostic importance and clinical significance of PET/CT findings in giant cell arteritis (GCA).Methods:Data of the patients who underwent PET/CT to investigate large vessel involvement and who had at least 6 months of follow-up with a clinical diagnosis of GCA were retrospectively evaluated. PET/CT images were assessed by an experienced nuclear medicine specialist, regions of interest were drawn for major vascular territories and standardized maximum uptake values (SUVmax) of these areas were recorded.Results:Twenty-nine consecutive patients (median age 68 (50-83), mean follow-up time 37.1 ± 48.8 (6-242)) were included into the study. All patients were over 50 years old and had erythrocyte sedimentation rate (ESR) over 50 mm/h at the time of imaging. Twenty patients (68.9%) met the ACR 1990 Classification criteria (ACR (+) group). The number of patients who had hypermetabolism in the aorta and its major branches in favour of LVV in PET/CT was 23 (79.3%) (PET-CT (+) group). Thoracic and abdominal aorta involvement were detected in 22 (75.8%) and 16 (55.2%) patients, respectively. There was positive correlation between SUVmax in thoracic and abdominal aorta on PET/CT and ESR at diagnosis (r = 0.63 p = 0.002 and r = 0.77 p Conclusion:PET/CT is increasingly used in the diagnosis and assessment of GCA in our center. The level of FDG uptake of the vessel wall in PET/CT correlates with the acute phase response. Flare was rarely observed in PET/CT (+) patients at diagnosis. Axillary artery involvement detected on PET/CT may be associated with the classical GCA clinic in ACR(+) patients (1). PET/CT (+) patients who does not met ACR criteria seems to have a diverse clinic features like young age and rare presence of PMR. PET/CT findings may be helpful in recognizing subgroups and predicting prognosis of GCA although prospective studies with follow-up scans are warranted.References:[1]Grayson PC, Maksimowicz-McKinnon K, Clark TM, Tomasson G, Cuthbertson D, Carette S, et al. Distribution of arterial lesions in Takayasu’s arteritis and giant cell arteritis. Annals of the rheumatic diseases. 2012;71(8):1329-34.Table 1.Comparison of patients who fulfilled and not fulfilled ACR 1990 classification criteria among PET/CT (+) patients.ACR (+) PET/CT (+)(n=14)ACR (-) PET/CT (+)(n=9)pOR (%95 CI)Age at diagnosis68,8±4,563.3±9,20.004PMR1020.0212.5 (1 – 6.1)History of flare41NSCRP at diagnosis75,1±30,6130,8±93,40.024ESR at diagnosis93,9±28,1112,5±21,2NSBrachiocephalic artery96NSRight subclavian85NSLef subclavian95NSRight carotid85NSLeft carotid96NSRight axillary700.0112 (1.18 – 3.3)Bilateral axillary600.0221.75 (1.1-2.7)Thoracic aorta SUVmax (mean)3,9±1,14,6±1,3NSAbdominal aorta SUVmax (mean)4,5±1,25,3±1,8NSDisclosure of Interests:None declared

Background:The prevalence of SLE pulmonary involvement varies depending on several factors, including diagnostic methods [1].Objectives:We aimed to determine the frequency of involvement with different diagnostic methods in a single center cohort.Methods:300 SLE patients were included. Chest x-ray (CXR), lung spirometry, carbonmonoxide diffusion test (DLCOc) and echocardiography were performed. High resolution thorax computed tomography (HRCT) was done for a definite diagnosis of interstitial lung disease (ILD) whilst diagram electromyography (EMG), ultrasonography (USG) and magnetic resonance imaging (MR) were utilized to diagnose shrinking lung syndrome (SLS).Results:The mean age and follow-up time were 43 and 11,5 years respectively. Of 300 patients, 16% had ILD, 6,7% had pulmonary hypertension (PHT), 3% had SLS, 0,3% had pulmonary infarction. At the start of the study, patients’ records showed that 4% had ILD, 5% PHT, 0,3% SLS and 0,3% pulmonary infarction. The median age, mean duration of disease and follow-up time were significantly higher and longer in patients with ILD compared to patients without (pConclusion:Interstitial lung disease is common in patients with SLE and considerable number of patients have SLS [2]. Spirometry, DLCOc and CXR are simple but valuable to diagnose pulmonary involvement in SLE patients. Diaphragm MR, USG and EMG are complementary methods for definite diagnosis in SLS [2]. Considering the significant difference of prevalence between the start and the end of the study, one of the possibbilities is the underrecognition of SLE pulmonary disease due to its being part of a multisystemic presentation. Higher usage of immunosuppressives in these patients may support a multisystemic active disease. Although drug effect is another concern, it is hard to establish a causal relationship due to the study’s cross-sectional design. HCQ may have a role in ILD prevention.References:[1]Keane MP, Lynch JP. Pleuropulmonary manifestations of systemic lupus erythematosus. Thorax 2000;55:159-166.[2]Singh R, Huang W, Menon Y, Espinoza LR. Shrinking lung syndrome in systemic lupus erythematosus and Sjogren’s syndrome. J Clin Rheumatol. 2002 Dec;8(6):340-5.Table 1.Spirometry; DLCO; diaphragm EMG, USG and MRI results of patients with SLS.Patient/Age/Sex1/44/F2/57/F3/39/F4/38/M5/23/F6/60/F7/58/F8/37/F9/66/F10/28/FFEV1 (%)47655963676271537039FVC (%)56735962797072556237DLCO (%)45504465535547656245TLC (%)61716566786454636245USG deep inspiration (L)4,704,742,593,013,063,065,734,172,121,59USG deep inspiration (R)3,721,982,262,242,772,174,672,834,622,49USG diaphragm thickness (L)4,823,002,482,842,551,592,093,181,621,44USG diaphragm thickness R(R)1,231,041,841,802,191,311,791,972,081,63MR high sideRRRRRRRLLMR height difference4,926,192,872,641,672,451,730,950,78EMG resting AMP (R)0,20,30,60,50,60,40,10,80,90,7EMG resting LAT (R)76,47,166,786,154,7565,8EMG resting AMP (L)0,40,50,80,71,20,60,31,20,50,5EMG resting LAT (L)6,355,756,855,66,05664,355,26,15Disclosure of Interests:None declared

Background:Pulmonary arterial hypertension (PAH) is a severe vasculopathic complication for systemic sclerosis (SSc) patients. The availability of oral-specific vasodilator therapies has provided better outcomes.Objectives:We aimed to analyze the characteristics of SSc-PAH patients and factors associated with mortality.Methods:Medical records of 291 SSc patients fulfilling ACR/EULAR criteria (2013) and followed–up during 2008-2020 years were screened and the patients who diagnosed PAH evaluated by right heart catheterization (mean PAB≥20 mmHg) (n=26, 8,9%) were included into this retrospective cross-sectional study.Results:The characteristics of 26 SSc-PAH(24 females) patients were summarised in Table 1.Table 1.Characteristics of SSc patients with PAHSSc-PAH(n=26)DemographicsAge(yrs)53.6±8.9Duration of Raynaud’s(yrs)16.1±11.8Duration of Non-Raynaud’s(yrs)9.2±6.6Raynaud’s to Diagnosis of PAH(yrs)10.8±6.7Clinical Characteristics (%)LcSSc9 (34.6)DcSSc18 (65.4)Digital ulcer14 (53.8)Gastrointestinal20 (69.0)Synovitis5(19.2)Flex contractures7 (26.9)Tendon friction rubs3(11.5)Renal crisis1 (3.8)Pulmonary fibrosis19 (73.1)Auto-antibodies (%)ANA23 (88.5)Anti-centromere6(23.1)Anti-Scl7013(50)Treatment (%)Specific vasodilatorERA (bosentan/macicentan/ambricentan)15 (51.7)PDE5-i (sildenafil/tadalafil)17 (58.6)Prostacyclin-analog (İloprost/treprostenil/selexipag)15 (51.7) Riociguat5 (17.2)Immunosuppressives21(80.8)Steroids16(61.5)Twenty-four (92,3%) of the SSc-PAH patients had PAH-related symptoms at the time of diagnosis, 2 (7,7%) were asymptomatic and diagnosed by screening. RHC and treatment details were stated in Table 2.Table 2.Right Heart Catheterization (RHC) ve treatment details of SSc-PAH patientsn=26Initial RHC -mean PAB30,4±7,9 (median 28, 20-53mmHg) -PVR5,1±2,4 (median 4, 3-9 woods) -PCWP10,8±5,5 (median 10, 0-15 mmHg)Initial treatment -monotherapy5 (19,2%) -combination10 (38,5%) -add-on combination12 (46,2%)Eleven out of 26 patients (42,3 %) were deceased after a mean follow up of 43,7±24,6 (median 48,1-84) from PAH diagnosis and 15,1±9,9 (median 13, 0,6-34) years after SSc diagnosis. Deceased patients were younger and had younger age at disease onset (49,1± 8,8 vs 56,9±7,7, p=0.032 and 30,8±13,0 vs 42.0 ±10,9, 0.027). All deceased patients had associated pulmonary fibrosis (100 vs 53.3%, p=0.01). No significant difference was observed for initial RHC parameters between deceased and survived SSc-PAH patients. Specific monotherapy was found to be more frequent in deceased patients (45,5 vs 0%, p=0,007).Conclusion:The prevalence of SSc-PAH was found to be 8.9% with increased mortality in our cohort. SSc-PAH patients predominantly had diffuse cutaneous involvement with digital vasculopathy, pulmonary fibrosis, and anti-Scl70 positivity. PAH was diagnosed after a median of 10 years of the Raynaud’s, mainly in symptomatic patients. Mortality in PAH-SSc patients was associated with early onset of disease, pulmonary fibrosis, and monotherapy. Initial RHC parameters were not found to be related to mortality.Disclosure of Interests:None declared.

Background:Psoriatic arthritis (PsA) is a heterogeneous disease and GRAPPA have proposed Minimal disease activity (MDA) as a composite outcome measure and has been validated in PsA.Objectives:In this study, we aimed to evaluate the characteristics, MDA frequencies, first biological disease modifying antirheumatic drugs (b-DMARD) continuation rate and associated factors in our PsA cohort.Methods:PsA patients who fulfilled the CASPAR classification criteria and had at least six months of follow-up data were evaluated cross-sectionally for MDA.Clinical data were collected from patient charts with standard forms.b-DMARD treatment was initiated in patients who did not respond to at least one conventional synthetic (cs) DMARD for at least three months. Only anti-TNFs were used as a first line b-DMARD therefore secukinumab (Secu) was used after first line b-DMARD treatment. Adalimumab, certolizumab, etanercept, golimumab were grouped as subcutaneous (s.c) anti-TNFs. MDA was defined as meeting five out of seven criteria during follow-up [1].Results:One hundred seventy-two patients (61% female) were included into the analysis. The mean follow-up time was 105.4±76 (6-444) months and the mean age was 50.2±13.3 (16-81) years. Mean age of onset for PsA was 38±11.9 (11-79) years; mean PsA and PsO duration were 140±90.7 (7.9-528) and 253±138 (0-756) months, respectively. Methotrexate was the most commonly used (88 %) cs-DMARD and biological DMARDs were used in 74 patients (43.3%)Overall, 95 patients (55.2 %) were observed at MDA which was significantly lower in b-DMARD users compared to only cs-DMARD users (45.9 % vs 61.9 %; p=0.038, OR: 4.3). MDA did not differ according to PsA subtypes. The addition of cs-DMARD treatment to b-DMARDs did not affect MDA frequency In univariate analysis; higher MDA frequency was associated with older age (p=0.002), longer PsO duration (p=0.036), late onset of PsA (p=0.007) and continuation of first b-DMARD (OR:13.9 pConclusion:Although frequency of MDA in our cohort was consistent with previous reports, a significant number of patients could not achieve MDA. Frequency of MDA was found to be lower in b-DMARD users compared to cs-DMARD users, possibly resulted from initiation of b-DMARD in patients with higher disease activity. Higher MDA rate was associated with higher continuation rate at first line b-DMARD treatment (TNF-inhibitor) and decreased gradually after b-DMARD switches. Although combined use of cs-DMARD with b-DMARDs did not increase the frequency of MDA, it was associated with higher b-DMARD retention. MDA is a useful outcome measure in daily follow-up of PsA patients and the importance of reaching sustained MDA for prognosis should be investigated further.References:[1]Coates, L.C., J. Fransen, and P.S. Helliwell, Defining minimal disease activity in psoriatic arthritis: a proposed objective target for treatment. Ann Rheum Dis, 2010. 69(1): p. 48-53.Table 1.b-DMARD responses, continuation rate and frequency of achieving MDA in patients with PsAb-DMARD treatmentMean (median) duration (month)Continuation rate n, (%)Primary inefficacy n, (%)Secondary inefficacy n, (%)MDAn, (%)First line b-DMARD (n=74)50.4 (36)37 (50)9 (24.3)17 (46)34 (45.9) *s.c TNF inhibitors (n=62; 83.8 %)50.8 (35.5)32 (51.7)8 (26.7)9 (30)31 (50) Infliximab (n=12; 16.2 %)13.8 (11)3 (25)1 (11.1)7 (77.8)3 (25)Second line b-DMARD (n=29)28.4 (13.5)15 (51.7)5 (35.7)3 (21.4)8 (27.6) *s.c TNF inhibitors (n=22; 75.9 %)28.6 (15)11 (50)4 (36.4)2 (18.2)5 (22.7) Infliximab (n=5; 17.2 %)35.2 (36)3 (60)--2 (40) Secukinumab (n=2; 6.9 %)9 (9)1 (50)1 (50)-1 (50)s.c:subcutaneousFigure 1.Comparison of b-DMARD retention according to MDA status in patients with ongoing first line b-DMARD treatment Log rank: p=0.001Disclosure of Interests:None declared

Background:Antiphospholipid syndrome (APS) is a chronic autoimmune disease with significant morbidity and mortality. The recently developed damage index for APS (DIAPS) considers thrombotic APS specific damage.Objectives:Herein we aimed to identify disease clusters based on clinical characteristics and compare DIAPS between these clusters in a single center cohort of patients with APS ± systemic lupus erythematosus (SLE).Methods:This retrospective study included 237 consecutive patients with APS [114 primary APS (PAPS) and 123 SLE+APS]. Data regarding demographics, clinical and laboratory characteristics and cardiovascular risk factors were retrieved from the existing database and revised. Two-step cluster analysis was performed. Cumulative damage was calculated for all patients by applying DIAPS as described previously.Results:237 patients were classified into 4 subgroups by cluster analysis. Cluster 1 (n=74) consisted of older patients with arterial-predominant VT, livedo reticularis and increased cardiovascular risk, cluster 2 (n=70) of SLE+APS patients with thrombocytopenia and heart valve disease, cluster 3 (n=59) of patients with venous-predominant VT, less extra-criteria manifestations and cluster 4 (n=34) of patients with only PM with a lower frequency of extra-criteria features and cardiovascular risk (table 1).Table 1.Demographic, clinical and laboratory characteristics of clustersAll (n=237)Cluster 1 (n=74)Cluster 2 (n=70)Cluster 3(n=59)Cluster 4 (n=34)PAge (years), median (range)43 (20-81)51 (20-81)40 (27-72)42 (24-69)40.5 (26-65)Duration of disease (years), median (range)9.5 (1-37.7)13.1 (1-37.7)10.4 (1-28.7)8.5 (1-32.8)7 (1-22.4)0.028Female, n (%)198 (83.5)56 (75.7)61 (87.1)47 (79.7)34 (100)SLE, n (%)123 (51.9)31 (41.9)46 (65.7)32 (54.2)14 (41.2)Vascular thrombosis, n (%)191 (80.6)73 (98.6)59 (84.3)59 (100)0 (0)Arterial thrombosis, n (%)109 (46)50 (67.6)31 (44.3)28 (47.5)0 (0)Venous thrombosis, n (%)112 (47.3)36 (48.6)37 (52.9)39 (66.1)0 (0)Pregnancy morbidity, n (%)117 (49.4)22 (29.7)46 (65.7)15 (25.4)34 (100)Livedo reticularis, n (%)38 (16)21 (28.4)10 (14.3)5 (8.5)2 (5.9)Thrombocytopenia, n (%)81 (34.2)4 (5.4)65 (92.9)4 (6.8)8 (23.5)Heart valve disease, n (%)92 (38.8)32 (43.2)46 (65.7)8 (13.6)6 (17.6)Arterial hypertension, n (%)101 (42.6)49 (66.2)34 (48.6)18 (30.5)0 (0)Hyperlipidemia, n (%)103 (43.5)69 (93.2)26 (37.1)0 (0)8 (23.5)Smoking, n (%)58 (24.5)31 (41.9)7 (10)17 (28.8)3 (8.8)Lupus anticoagulant, n (%)156 (65.8)53 (71.6)48 (68.6)35 (59.3)20 (58.8)0.36Anticardiolipin IgG/IgM, n (%)155 (65.4)46 (62.2)46 (65.7)38 (64.4)25 (73.5)0.71Anti-β2-glycoprotein I IgG/IgM, n (%)93 (39.2)25 (33.8)33 (47.1)26 (44.1)9 (26.5)0.13Triple aPL positivity, n (%)45 (19)12 (16.2)16 (22.9)13 (22)4 (11.8)0.46Cluster 2 had the highest cumulative damage (mean DIAPS 2.48 ± 1.67) followed by cluster 1 (2.24 ± 1.44), cluster 3 (1.69 ± 1.27) and cluster 4 (0.32 ± 0.68). Comparison of DIAPS (total and major domains) between the clusters is shown in figure 1.Patients with SLE+APS had a higher mean DIAPS compared to those with PAPS (2.10 ± 1.61 vs 1.69 ± 1.47, P=0.046). Cardiovascular domain was the most frequently affected DIAPS domain in both groups. Proteinuria and avascular necrosis were significantly more frequent in SLE+APS (9.8% vs 2.2%, P=0.02 and 5.7% vs 0%, P=0.009, respectively). DIAPS was positively correlated with disease duration (r=0.192, P=0.003).Conclusion:Elder APS patients with arterial thrombosis and increased cardiovascular risk and SLE+APS patients with extra-criteria manifestations had higher cumulative DIAPS. Longer disease duration, higher frequency of major organ involvement and higher immunosuppressive usage may have contributed to this difference. Therefore, control of cardiovascular risk factors, prevention and effective treatment of SLE flares may help to reduce damage in these subgroups.Figure 1.Comparison of mean DIAPS (total and major domains) between the clustersDisclosure of Interests:None declared

Background:The rates of hospitalization in patients with SLE is around 10% per year.1Objectives:In this study, we aimed to examine the hospitalization data of patients with SLE in the last 5 years at our center and determine the factors that affect hospitalization.Methods:Hospitalization data of patients with SLE (2012 SLICC classification) admitted to our rheumatology ward between January 2015 and 2020 were analyzed. Cumulative clinical and laboratory findings were retrieved from the existing SLE database and revised. SLICC SLE damage index (SDI), and the disease activity at admission were determined (SLEDAI-2K).Results:Eighty-six % (n=138) of 161 hospitalized patients were female. The mean age of the patients was 38 ± 13 years whilst mean duration of disease was 97.3 ±96.9 months. Thirty-eight% of the patients were hospitalized more than once and the mean number of hospitalizations was 1.8±1.5 The mean hospitalization duration covering all stays for each patient was 25±27 days. Active disease followed by infection and damage-related complications ranked the first three among all causes of hospitalization.Compared to patients hospitalized for active disease or other reasons, patients hospitalized for infection had a significantly higher number of readmissions (p) and their total duration of hospitalization was longer (p). Duration of disease was significantly shorter in patients hospitalized for active disease compared to patients hospitalized for infection and damage related causes (pThe frequency of patients with damage and the mean SDI score was significantly lower in the group with active disease (68% and 1.9 ± 2) compared to patients hospitalized for infection (90% and 2.7±1.6) and other causes (96% and 3±1.7) (pp) as well as the number of hospitalizations (r=0.393, p). Regarding disease activity at the time of admission, the mean score of patients hospitalized for active disease was 11.0 ± 6.1 whilst was 3.2 ± 2.8 in patients hospitalized for infection and 2.9 ± 3.3 in patients hospitalized for other reasons (p). Renal active disease was the most common (44%), followed by hematological (34.8%), articular (21.7%) and mucocutaneous (21%) activity. Ten% of the patients all of whom had damage were admitted to intensive care unit (ICU). Total hospitalization duration (p=0.012), mean SDI (p=0.008), antiphospholipid syndrome (p=0.033), lupus anticoagulant (p=0.010), thrombocytopenia (p=0.015), serositis (p=0.034), pulmonary hypertension (p=0.021), history of alveolar haemorrhage (pcardiac valve involvement (p=0.002) were associated with ICU hospitalization.Conclusion:Disease activity, infections and damage are the leading causes of hospitalization in patients with SLE. Damage increases the frequency of hospitalizations, prolongs the duration of stay, and increases the need for follow-up in the ICU. Tight control of disease activity with rational use of immunosuppressive treatment is important to reduce damage and hospitalizations.Graphic 1.Distribution of damage according to organs/systems in hospitalized patientsReferences:[1]Gu K, Gladman DD, Su J, Urowitz MB. Hospitalizations in patients with systemic lupus erythematosus in an academic health science center. The Journal of rheumatology 2017;44:1173-8.Disclosure of Interests:None declared

Objective To determine the relationship between vascular biomarkers reflecting the vascular injury and neoangiogenesis with capillaroscopic changes in systemic sclerosis (SSc). Methods Nailfold video-capillaroscopy (NVC) was performed qualitatively (early, active and late scleroderma patterns) in 72 SSc patients (66 female) fulfilling ACR/EULAR (2013) criteria. Serum samples of patients were collected and analysed by flow cytometer with multiplex kits of sCD40L, tPA, MCP-1, sE-selectin, IL-8, IL-6, VEGF, sP-selectin, TGF-β1 and VCAM at the same time with NVC. Results Compared to healthy subjects; tPA ( p = 0.02), MCP-1 ( p = 0.001), sE-selectin ( p = 0.008) and TGF-β1 ( p = 0.001) levels were significantly higher, however sP-selectin ( p = 0.011) and IL-8 ( p = 0.001) levels were lower in SSc patients. SSc patients were defined according to NVC patterns as ‘early’ ( n = 10), ‘active’ ( n = 37) and ‘late’ ( n = 25). According to NVC patterns of SSc patients, only sCD40L levels were significantly lower in the ‘late’ group ( p = 0.039). The other markers were similar among NVC groups. Conclusions NVC is a useful method for investigating the vascular pathogenesis and severity of SSc. Although the levels were similar to healthy controls in patients with early/active NVC patterns, there were lower sCD40L serum levels in patients with late NVC pattern. CD40L may have a role in the early/active phase of vascular involvement.

Background Assessment of disease activity in systemic sclerosis (SSc) is challenging and usually hard to distinguish from damage or chronicity. Objectives We aimed to evaluate disease activity by different indexes and compare them in a SSc cohort. Methods Disease activity was evaluated by revised EUSTAR (European Scleroderma Trials and Research group) and EScSG (European Scleroderma Study Group) activity indexes in 131 SSc patients fullfiling ACR/EULAR classification criteria (2013). The patients with the scores of EUSTAR activity index ≥2.5 or EScSG activity index ≥3 were accepted as having active disease. Results Demographics, disease characteristics and nailfold video-capillaroscopic (NVC) pattern details were summarised in table-1. The scores of EUSTAR and EScSG activity indexes were correlated well (r=0.576, p=0.000) and the agreement between two scores for activity was moderate (cohen kappa:0.407). The percentages of SSc patients described as having active disease or not according to two activity indexes were summarised in table-2. Of the patients, 9.9% had active and 70.9% had inactive disease according to both indexes in this SSc cohort. Twenty -one (for EUSTAR) and 4 patients (for EScSG) were described as active according to one index and not to the other. Revised EUSTAR activity index was found to have 76.5% sensitivity and 81.6% specificity when the activity was defined by EScSG activity index. Conclusion This SSc cohort predominantly had limited cutanous disease, digital vasculopathy and late scleroderma pattern. Defining active disease was differed in 19% of the patients according to EUSTAR and EScSG activity indexes, former described higher frequency for activity. This difference might be related to validation procedures of these indexes in patients with different predominant stages of SSc disease, content of the index and the features of the cohort. Disclosure of Interests None declared

Background:AA amyloidosis has been associated with uncontrolled chronic inflammatory diseases such as rheumatoid arthritis (RA), ankylosing spondylitis (AS), inflammatory bowel disease (IBD) and hereditary periodic fever syndromes, and the most common cause is familial Mediterranean fever (FMF) in Turkey.Objectives:We herein aimed to evaluate clinical and laboratory characteristics and treatment responses of patients with AA amyloidosis retrospectively in a tertiary referral center.Methods:Study group was consisting of patients with biopsy proven AA amyloidosis, and their data were recorded from their charts. Treatment responses were categorized as follows:complete responsewas defined as no increase in serum creatinine and a proteinuria below 1gr/day;partial responseas 50% decrease in proteinuria; andstable disease as no significant change in serum creatinine and proteinuria. Progressive disease was defined as increase in serum creatinine and/or proteinuria under treatment.Results:173 patients were identified, and 10 patients with no biopsy result and/or missing data were excluded. A total of 163 patients (79 females, 84 males) were included in the study. Median age of patients was 45.4, and median age at diagnosis of amyloidosis was 33.5. Most common cause of amyloidosis was FMF (78.5%), followed by idiopathic cases (7.9%) and patients with AS (4.9%). A quarter (26%) of amyloidosis patients had a family history for AA amyloidosis, and 59% of patients with FMF had a family history of FMF. Amyloidosis was confirmed by renal biopsy in 76.1%, by gastrointestinal (GIS) biopsy in 11.7%, and by other biopsies in the remaining. Renal involvement was documented in 160 (98.2%) patients, while GIS involvement in 20.9%, heart in 13.5%, thyroid in 3.7% and bone marrow in 3.1%. In FMF patients, most common MEFV mutation was M694V (77.7%); and 66.7% of the patients had homozygous, 14.6% had compound heterozygous, and 18.7% heterozygous exon 10 variants. Mean age at diagnosis of amyloidosis was earlier in homozygotes (29.1) and compound heterozygotes (32.3) compared to heterozygotes (43.9) (p = 0.001). There was no difference in treatment responses, organ involvement, progression to end stage renal disease (ESRD) and mortality between monoallelic and biallelic exon 10 mutations (p = 0.42). While 44.3% (n = 70) of patients had chronic renal disease (CRD) at time of diagnosis, ESRD developed in 45.3% (n = 73) of patients. During follow-up, 55 patients underwent renal transplantation and recurrence of renal amyloidosis occurred in 24% of them. Mean creatinine and proteinuria levels at time of diagnosis were higher in patients with ESRD than those without ESRD (p Figure 1: Survival graphic of AA amyloidosis patients who developed ESRD according to their baseline GFR statusConclusion:Increased rate of ESRD and progression of amyloidosis findings in patients who presented with GFRDisclosure of Interests:None declared

Background:Treatment options for systemic sclerosis (SSc) remain limited especially in severe skin, lung and musculoskeletal involvements. B-cell targeted therapy with anti-CD20 Rituximab (RTX), is widely available, reports from case series are encouraging as a a rescue therapy and might have an improving effect on organ involvement in SSc.Objectives:We aimed to retrospectively analyze the efficacy and safety of rituximab (RTX) courses in patients with severe systemic sclerosis who were refractory to standard immunosuppressive treatment.Methods:Twenty-seven SSc patients fulfilling ACR/EULAR classification criteria (2013) who received RTX treatment due to acive disease despite treatment with immunosuppresives were analyzed. Disease activity was evaluated by using EScSG/EUSTAR activity scores prior to and after RTX treatment. Disease severity was also assessed at baseline by Medsger’s index.Results:The demographics and characteristics of SSc patients were as follows: the median age of 50 (30-70), duration of Raynaud’s 10 (3-26) and non-Raynaud symptom 8.5 (3-18) years and summarised in table 1. RTX was given as a single cycle (2 infusions of 1000 mg) in 12 cases, 2 cyles in 5 cases, ≥3 cyles in 10 cases. DMARDs were prescribed in 19 (73%) patients (14 MMF, 5 MTX) concomitantly with RTX. The main RTX indications were skin and lung involvement (n=9), skin and arthritis (n=6), skin(n=5), lung (n=3), myositis (n=2), cardiac involvement (n=1) and digital vasculopathy (n=1). Medsger severity score was 7.39±3.091(3-13) at baseline.Table 1.Prevelance of Characteristics of SSc Patientsn(%)female/male25 /2diffuse/limited cutaneous SSc22 (81.5) / 5 (19,2)Clinical Characteristicssynovitis / flexion contractures12(44,4) / 10 (37,1)tendon friction rubs / myositis7 (26,9) / 4 (15,4)renal crisis1 (3,8)GI involvement19 (69,2)lung involvement16 (61,5)SerologyANA23 (85,2)Anti-Scl70 / Anti-sentromer16(61,5) / 1(3,8)Anti-Ro6 (22,2)Previous ImmunosuppressivesCYC / MMFAZA / MTX Low dose steroids19 (73,1) / 19 (73,1) 12 (46,2) / 16 (61,5) 27 (100)Disease activity and severity scores prior to and after RTX were summarised table 2. Disease activity scores were improved after RTX in patients who had a median follow-up period of 1 year (0,5-5 years). After RTX treatment, according to EscSG /EUSTAR scores 13 (%46.2) and 10 (%34.6) patients out of 26 were assessed as inactive.Table 2.Disease activity scores prior to and after RTX treatmentPrior to RTX (n=26)After RTX (n=18)median Δ Change (n=18)EscSG activity score4,89±1,82 (2,0-9,0)2,37±1,10 (0,50-4,50)-2,00 (PEUSTAR activity score4,57±2,68(1,0-10,0)2,30±2,15 (0,0-7,25)-2,00 (P=0,002)There were severe infecions in 4 patients (Pneumonia in 2, infected digital ulcers in 2) and an episode of sinusitis in one during treatment period. One patient was deceased because of pneumonia and sepsis after the first cycle of RTX.Conclusion:In our SSc cohort, RTX treatment was used in severe patients, who had predominantly diffuse cutaneous disease with lung and joint involvements, severe vasculopathy and anti-Scl-70 positivity. Concomitant DMARDs were used in three-forth of the patients in addition to RTX cycles. Disease activity scores that assessed retrospectively were shown to be improved after RTX and 37-48% of the cases were assessed as inactive by using activity scores. Serious infections like pneumonia and infected digital ulcers were observed in 14,8% of cases during the follow-up. The addition of RTX treatment can be effective in selected patients with active disease despite immunosuppressive therapy.Disclosure of Interests:None declared

Background:The prevalence of giant cell arteritis (GCA) in Turkey has been reported lower than other European countries and the information on clinical patterns, diagnostic modalities, treatment and prognosis of GCA are limited (1).Objectives:We aimed to analyse our GCA cohort from a large outpatient clinic for the last 20 years.Methods:Data of the GCA patients followed up at least for 6 months in our vasculitis clinic between 1998 and 2018 evaluated retrospectively according to EULAR 2018 GCA clinical research recommendations (2). Chi-square, students t-test, logistic regression analysis and Kaplan-Meier test were used for statistical analysis.Results:Eighty-nine patients with adequate follow-up data (64% female, mean age 67.9 ± 9.1) were analysed. Median follow up duration was 46 months (3-256) and mean time to diagnosis after presenting symptom (TTD) was 5,9±1,2 months (0-60). Polymyalgia rheumatica was found in 36 (40.4%) patients. The clinical findings of the patients are shown in Table-1. Mean TTD was longer in patients with acute vision loss (AVL) (11±4 vs. 4,8±1,1 months p=0.002). Mean CRP was 90,7±82 (8-343) mg/L and ESR was 103,7±25 (52-138) mm/h at the time of diagnosis. Mean age was lower (63±2 vs 69±1 p=0.01); mean CRP (141,8±107,3 vs. 76,6±67,9 mg/dL p=0.023) and ESR (120,8±25,1 vs. 99,3±24,3 mm/h p=0.004) was higher in patients without cranial symptoms (extracranial GCA group). PET-CT findings compatible with large vessel vasculitis were present in 64% (34/53). Sixteen of 19 (%84,2) patients in the extracranial GCA group had positive PET-CT. Temporal artery (TA) biopsy positivity was 64% (34/53). Sensitivity of ACR 1990 Criteria was 77,5% and GIACTA study inclusion criteria was 58,4% in this cohort at diagnosis. Fullfilment of GIACTA criteria was still present in 12 (13,5%) patients after six months of follow up. Treatment data was shown in table-2. Total flare rate was 34,8% and flare risk was lower in the extracranial GCA group (3/20 vs. 28/69 p=0.035 OR=0.78 %95 CI 0.64 – 0.96). Reduced survival was observed in cases diagnosed older than 65 years (168,8±23,9 vs 209±17,3 months p=0,015).Conclusion:The analysis of the largest single center cohort from Turkey confirmed that delayed diagnosis is associated with vision loss. A subgroup of patients without apparent cranial symptoms but positive PET-CT findings is delineated. These patients are younger, present with higher inflammatory response and fewer relapses. The sensitivity of ACR criteria in our cohort is less than 80%. High flare rate especially in GCA patients with cranial symptoms and GIACTA criteria fullfilment after 6 months of treatment in more than 10% of the patients show a need for for new treatment options.References:[1]Pamuk, O.N., et al.,Giant cell arteritis and polymyalgia rheumatica in northwestern Turkey: Clinical features and epidemiological data.Clin Exp Rheumatol, 2009.27(5): p. 830-3.[2]Ehlers, L., et al.,2018 EULAR recommendations for a core data set to support observational research and clinical care in giant cell arteritis.Ann Rheum Dis, 2019.78(9): p. 1160-1166.Table 1.Clinical characteristicsSystemic / Extracranial Findings78 (%87,6)Cranial Findings69 (%77,5)Opthalmologic Findings20 (%22,5)Fatigue72 (%80,9)Headache60 (%67,4)AVL16 (%18,8)Weight loss47 (%52,8)Jaw claudication33 (%37,1)Unilateral12 (%13,5)Arthralgia43 (%48,3)Scalp / TA Tenderness27 (%30,3)Bilateral4 (%4,5)Fever35 (%39,3)Decreased pulsation of TA11 (%12,4)Diplopia4 (%4,5)Arthritis13 (%14,6)CVE6 (%6,7)Vascular murmur3 (%3,4)Swollen TA6 (%6,7)Pericardial effusion2 (%2,2)Vertigo5 (%5,6)Extremity Claudication1 (%1,1)TABLE 2Treatment data of GCA cohortInitial glucocorticoid (GC) dosage (mg)46,7±20,1Pulse GC treatment%12,312nd month cumulative GC dosage (g)4,7±2,5MTX usage%63,3bDMARD usage%6,7Acetyl salicylic acid usage%51,7Disclosure of Interests:None declared

Background:Evaluating disease activity and severity in systemic sclerosis (SSc) is crucial to define the patients who are candidate for treatment options.Objectives:We aimed to investigate the relationship between disease activity and severity in SSc in a large cohort.Methods:This is a cross-sectional prospective analysis of 278 (253 females) patients fulfilling ACR/EULAR (2013) classification criteria for SSc. Disease activity and severity were calculated seperately for cutaneous subsets (EscSG and Medsger). The patients were grouped as inactive if EscSG score=0, mildly active if EscSG score>0Results:The mean age, duration of Raynaud’s and non-Raynaud features were 48.5±13.1, 12.1±9.8 and 8.3±7.5 years respectively. Characteristics of the SSc patients were summarized in table-1.Ninety-three (34%) and 151(54%) patients were evaluated as having active and mildly active disease. Only 34(12%) patients had inactive disease. The patients with diffuse cutaneous involvement (dcSSc) who were active had higher modified Rodnan Skin score(mRSS) and severity scores of general, skin and joint-tendon involvements; the patients who had mildly active disease also had higher scores of mRSS and severity scores of skin compared to those with inactive disease (table-2).The patients with limited cutaneous involvement (lcSSc) who were assessed as having active disease had higher mRSS and higher severity scores of general, skin, peripheral vascular, lung, joint-tendon and gastrointestinal involvements; the patients who had mildly active disease also had higher scores of mRSS and severity scores of skin, lung, joint-tendon and gastrointestinal involvements compared to those with inactive disease (table-2).Conclusion:One third of our cohort was found to have active disease despite treatment and only 12% had inactive disease. Skin involvement and severity of different organs were shown to be higher in patients with active disease in both cutaneous subsets, together with severity of lung, peripheral vascular and gastrointestinal involvements in active lcSSc. LcSSc and dcSSc patients who had mildly active disease also had severe disease similar to those with active patients. Disease activity and severity should be assessed as separate measurements to highlight the course of the disease and may guide to the management of patients with SSc.Disclosure of Interests:None declared

Background:Development of organ damage is a major concern in patients with systemic vasculitis. Treatment may also contribute to this important outcome. Scoring systems has been developed to evaluate organ damage in systemic vasculitis and specifically for large vessel vasculitis (1).Objectives:We aimed to investigate permanent organ damage and determining factors in our giant cell arteritis GCA cohort.Methods:Organ damage detected at the time of diagnosis and / or follow-up and irreversible for at least 3 months in GCA patients followed up between 1998-2018 were recorded by using Vasculitis Damage Index (VDI) and Vascular Vasculitis Damage Index (LVVID) fom patient records of our vasculitis clinic. In the statistical evaluation, chi-square, students t-test and logistic regression analysis were used.Results:Eighty-nine patients (64% women, mean age 67.9 ± 9.1) included in the study, the mean follow-up duration was 61.6 ± 58.6 months. All organ damage findings according to both VDI and LVVID are shown in table-1. In this cohort, cardiovascular damage items and diabetes mellitus were prevalent at baseline. At least one damage item was present in 53 (59,5%) according to VDI; 54 (%60,7) according to LVVID and agreement was high between two damage indices (kappa=0.97). Forty-seven of patients (52%) had a damage item presumably with contribution of GC treatment e.g. locomotor system findings, hypertension, diabetes and cataract; 12 (13,5%) had damage items related to disease (total or partial vision loss, ischemic optical neuropathy). Mean time to diagnosis after initial symptoms was longer in patients with permanent vision loss (10,2±4,3 vs. 5,2±1,2 months p=0.006). The presence of damage was associated with flares in univariate and multivariate analysis (29/54 vs. 2/35 pConclusion:In our study, permanent organ damage was analysed by using diffrerent indices. In this patient population baseline cardiovascular damage and diabetes mellitus were frequent as expected but information for osteoporosis was lacking. More than half of the patients had damage and significant part of the present items was considered due to corticosteroid treatment. The most common damage item developed was osteoporosis. There was a very good agreement between the two indices, despite few specific items in LVVID. The striking relationship of disease flare with damage and frequency of visual problems despite treatment indicate the necessity of new treatment strategies.References:[1]Kermani, T.A., et al.,Evaluation of damage in giant cell arteritis.Rheumatology (Oxford), 2018.57(2): p. 322-328.Disclosure of Interests: :None declared

Background:Serious infections (SI) are one of the main complications in patients with ANCA associated vasculitis (AAV).Objectives:We planned to investigate the prevalence, features and risk factors of SI in our AAV cohort during follow-up.Methods:Outpatient and hospital data of patients diagnosed with granulomatous polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatous polyangiitis (eGPA) between 1999 and 2019 according to Chapel Hill Consensus Criteria and followed up at least 6 months in our vasculitis clinic were evaluated. Development of sepsis, requirement for intravenous (IV) antibiotherapy and / or hospitalization during infection episodes were considered as SI. Chi-square, student’s t-test and logistic regression analysis were used for statistical analysis.Results:Study was conducted with 186 (53.6% female) patients with adequate follow-up data. Mean age of diagnosis was 54.3±14,5 (23-79), mean follow-up duration was 86,4 ± 54,3 (6-251) months. Number of GPA, MPA and eGPA patients were 132 (71%), 42 (22,5%) and 12 (6,5%), respectively. IV cyclophosphamide (CYC) was used in 148 (79,6%), azathioprin in 105 (56,5%), rituximab (RTX) in 69 (%37,1), methotrexate in 29 (15,6%) and mycophenolate mofetil in 14 (7,5%) patients. Number of patients developed SI was 66 (34.7%), total SI episode was 86, patients who had multiple episodes was 15. All SI is shown in Table-1. Bacterial pneumonia was the most common diagnosis and 26 of SI (30.2%) were considered as opportunistic (systemic viral, parasite, fungus) infections. Thirty-one of patients developed SI (40,7%) in the first year after diagnosis. SI were observed more frequently in the presence of major organ involvement (kidney, lung, neurological) (65/173 vs. 1/13 p = 0.02 OR = 8.7 95% CI 1.06-64.4). Diffuse alveolar hemorrhage (DAH) was associated with SI in multivariate analysis (12/52 vs. 0/34 p=0.007 OR=1.6 95% CI 1.3-1.96). Cumulative CYC dose was significantly higher in patients with SI (14,2±21 vs. 8.2±13.9 p=0.045). During maintenance, patients treated with RTX had significantly more SI (18/53 vs. 17/99 p=0.19 OR=3,3 95% CI 1,55- 7,07). Hypogammaglobulinemia (HIgG) (IgGConclusion:Long-term follow-up results of a single center cohort of AAV patients revealed that approximately one third of patients developed SI, most frequently in the first year of treatment. During the maintenance period, the risk of SI continues. Cumulative CYC dosage and maintanence with RTX is associated with SI, especially in patients who developed hIgG. Major organ involvement, disease flares and organ damage are significant risk factors for SI. In this regard, protection measures (vaccination, prophylaxis) should be reviewed and the quality of follow-up should be improved.Table 1.Serious infections in AAV patients.BACTERIALNFUNGALNVIRALNPROTOZOANNPneumonia37PJP7Zoster Zona3Intramuscular abscess (Nocardiosis)1Urinary Tract Infection (UTI)8Aspergilloma1CMV Pneumonia1Gr (-) sepsis2Invasive Fungal Infection3CMV Colitis1Perianal abscess2Candida Eosephagitis4CMV Gastritis1Intraabdominal abscess2Candidemia2HSV Eosephagitis1Catheter infection2UTI1Sellulitis1Fungal otitis1Orbital sellulitis1Maxillary sinüs abscess1Mastoiditis1Prosthesis infection1Septic artrhitis1Lung tuberculosis1Disclosure of Interests:None declared

Background:Hydroxychloroquine (HCQ) is an immunomodulatory drug that has been shown to improve disease activity in systemic lupus erythematosus (SLE). However, retinal toxicity is an important concern.Objectives:In this study we sought to evaluate the effect of HCQ on disease activity and damage in patients with SLE in whom HCQ was discontinued due to retinal toxicity and whether it could be restarted by a detailed ophthalmologic examination.Methods:Patients who met SLE SLICC classification criteria and were on HCQ for at least 3 years after reaching Lupus Low Disease Activity State (LLDAS) following remission induction and were followed up for at least 3 years after termination of HCQ treatment due to retinal toxicity diagnosed with visual field test were analyzed. Disease activity (LLDAS and SLEDAI-2K) and both the number and severity of flares were recorded for each patient whilst on HCQ and after cessation of treatment. All patients were examined by two experienced ophthalmologists and were assessed by computerized visual field, optical coherence tomography (OCT), fundus autofluorescence (FAF) and fundus florescein angiography (FFA) to further analyze toxicity.Results:Out of 88 patients with recorded HCQ retinal toxicity in a cohort of 1500 patients with SLE, 64 patients (mean age at diagnosis 33.4 ± 10.5 (10-57); 88.5% female) with complete data and opthalmologic re-examination results were included in the analyses. The average duration on HCQ was 122 ±85 (39-336) months, and the mean follow-up time was 74.6 ± 48.3 (36-239) months after the drug was discontinued. Comparison of mean disease activity in the 3-year period when patients were on HCQ to 3 years post-cessation revealed a significantly lower mean SLEDAI-2K score in the former (0.89±1.28 vs.1.3±1.6, p=0.02). The % of visits maintaining LLDAS was higher during HCQ treatment (89.7 ± 17.6 vs. 80.1 ± 23.5, p=0.001). There was significantly a higher frequency of flares with a dominance of mild-moderate types after HCQ was ceased (47.5 vs. 26.2%, p=0.03; 39.3 vs. 22.9%, p=0.024 respectively). There were more patients with serious flares in the post-discontinuation period but without statistical significance (13.1% vs. 4.9% p=0.08). Thirty-seven (60%) of patients restarted the treatment after ophthalmological examination. Although 38 (62,3%) patients had visual field defects in the latest examination, multimodal imaging with OCT, FAF and FFA revealed that only 19 (31%) patient had typical retinal toxicity. Five patients were found to have macular atrophy due to other causes (4 age related macular degeneration and 1 vitromacular adhesion). Since the discrimination of macular pathology would not be possible with imaging in these patients, HCQ was not prescribed. Comparison of patients with and without retinal toxicity showed that duration of HCQ use and HCQ-free time was not significantly different between patients.Conclusion:HCQ is effective in controlling disease activity in patients with SLE and an opportunity for re-medication with HCQ is valuable. More than half of the patients being able to restart HCQ after ophthalmologic examination in this study shows that it is important to perform multimodal imaging techniques in patients with retinal toxicity diagnosis. Since macular pathology can have a different etiologic background, an initial opthalmologic examination is also necessary. Lack of difference in the duration of HCQ exposure and drug-free time between patients who restarted treatment and who could not may be a sign of personal sensitivity to HCQ toxicity.Disclosure of Interests: :None declared

Background:Adjusted global antiphosholipid syndrome score (aGAPSS) is the simplified version GAPSS that was recently developed to assess thrombotic risk by the consideration of antiphospholipid antibody (aPL) profile and conventional cardiovascular risk factors.Objectives:The aim of this study was to evaluate the validity of the aGAPSS in predicting thrombosis and extra-criteria manifestations in our antiphospholipid syndrome (APS) cohort.Methods:Ninety-eight patients with APS were classified according to clinical manifestations as vascular thrombosis (VT), pregnancy morbidity (PM) or both (VT+PM). The aGAPSS was calculated as defined before. Arterial hypertension and hyperlipidemia definitions were made according to the ESC/ESH ve NCEP/ATP III guidelines, respectively.Results:Demographic, laboratory and clinical characteristics of patients are summarized in table-1. Mean aGAPSS was calculated as 10.2 ± 3.8. Significantly higher aGAPSS values were seen in VT (n=58) and VT+PM (n=29) compared to PM (n=11) (mean aGAPSS 10.6 ± 3.7 vs 7.3 ± 2.9, P=0.005; 10.5 ± 4 vs 7.3 ± 2.9, P=0.01, respectively). AUC demonstrated that aGAPSS values ≥ 10 had the best diagnostic accuracy for thrombosis (figure-1). Higher aGAPPS values were also associated with recurrent thrombosis (mean aGAPSS 11.5 ± 3.7 vs 9.9 ± 3.6, P=0.04). Regarding extra-criteria manifestations, patients with livedo reticularis (n=11) and APS nephropathy (n=9) had significantly higher aGAPSS values (mean aGAPSS 12.9 ± 3.4 vs 9.9 ± 3.7, P=0.02; 12.4 ± 2.9 vs 10 ± 3.8, P=0.04, respectively).Conclusion:Our results suggest that patients with higher aGAPSS values are at higher risk for developing vascular thrombosis (either single or recurrent) and extra-criteria manifestations, especially livedo reticularis and APS nephropathy.Table-1.Demographic, laboratory and clinical characteristics of patients.PAPS (n=42)n(%)SLE/APS (n=56)n(%)PFemale36 (85.7)47 (83.9)0.52Age, years (mean±SD)44.6 (11.6)40.8 (10.1)0.42Disease duration, years (mean±SD)10 (8.8)9.7 (7.1)0.16Thrombosis35 (83.3)52 (92.9)0.12•Arterial24 (68.6)34 (65.4)0.47•Venous19 (54.3)26 (50)0.43•Recurrent15 (42.9)22 (42.3)0.56Pregnancy morbidity20 (47.6)20 (35.7)0.16•5 (25)4 (20)0.5•≥ 10 weeks, ≥ 1 abortion14 (70)15 (75)0.5•Pre-eclampsia/eclampsia3 (15)5 (25)0.34•1 (5)5 (25)0.09Convensional risk factors•Arterial hypertension17 (40.5)35 (62.5)0.02•Hyperlipidemia21 (50)26 (46.4)0.41•Diabetes mellitus3 (7.1)3 (5.4)0.51•Obesity19 (45.2)16 (28.6)0.07•Smoking12 (28.6)18 (32.1)0.43aPL profile•LA29 (69)48 (85.7)0.04•aCL IgG/IgM31 (73.8)28 (52.8)0.03•aβ2GPI IgG/IgM22 (56.4)27 (52.9)0.45•Triple positive14 (33.3)17 (30.4)0.46Figure 1.ROC curve according to cut-off aGAPSS value: 10 (AUC: 0.71, sensitivity: 0.52, specificity: 0.91, positive predictive value: 0.98, negative predictive value: 0.19, p-value: 0.01).Disclosure of Interests:None declared

Background:ANCA-associated vasculitis (AAV) is a multisystemic autoimmune disease with high mortality and morbidity.Objectives:We aimed to present the long-term follow-up results of our cohort.Methods:Data of patients who fulfilled Chapell Hill Consensus Criteria and followed up at least 6 months between 1999-2019 were analyzed. A standard form including vasculitis damage index (VDI) was used. Multivariable analysis was performed by using logistic regression.Results:Long-term data was available for 197 patients (%53.8 female) from 208 patient records. Mean age at diagnosis was 49.4 years and mean follow-up was 80.7 months. Granulomatosis with polyangiitis (GPA); microscopic polyangiitis (MPA), eosinophilic GPA (EGPA) were 117 (64.5%), 52 (26.4%), 17 (8.6%), respectively. Relapses are observed in 31.6% of patients. Disease relapses were higher in GPA compared to MPA and EGPA (p = 0.014). Relapse rate was higher in patients withs.aureuscarriage (p = 0.037). Cyclophosphamide (CYC) (76.6%) was most commonly used drug for induction, whereas azathioprine (57.3%) was used mostly in maintenance. In multivariate analysis relapse was found to be associated with maintenance treatment with rituximab (p Conclusion:In our AAV cohort, GPA was most frequent. Although survival was improved, permanent organ damage was detected in the majority of patients. Relapse and organ damage were found to be increased in patients with GPA. Relapses are frequent and maintenance with rituximab could not prevent relapses. Also relapses were associated with venous thrombosis and severe infections. Patients should be screened for malignancies especially of the genitourinary tract.Table 2.Damage findings of AAV patients according to VDIOrgan/systemNumber(%)Steroid myopathy23 (%11.7)Osteoporosis31 (%15.9)AVN30 (%15.4)Cataract30 (%15.4)Partial loss of vision6 (%3.1)Blindness (one eye)2 (%1)Subglottic stenosis9 (%4.5)Hearing loss18 (%9.1)Nasal septum perforation21 (%10,7)Chronic nasal crusting9 (%4,6)Chronic ashtma28 (%14,2)Chronic dispnea1 (%0,5)Hypertension60 (%30,5)Coronary artery disease / Angioplasty10 (%5,1)Cardiomyopathy6 (%3)Valvular heart disease5 (%2,5)Myocardial infarction7 (%3,6)Deep vein thrombosis12 (%6)Chronic renal failure (GFR 51 (%26)End stage renal disease22 (%10.8)Cerebrovascular accident9 (%4,4)Peripheric neuropathy39 (%19.8)Malignancy9 (%4.5)Diabetes mellitus24 (%12.2)Gonadal failure2 (%1)Figure 3.Cumulative Relapse Rate: Hazard ratio of patients treated with Rituximab versus Azathioprine (Log Rank: pDisclosure of Interests:None declared

Introduction: Rheumatoid arthritis (RA), which is an autoimmune disease with chronic joint inflammation, is usually associated with pleural parenchymal involvement. Nodules can be seen in lung parenchyma but cavitary properties are rare. Methods: Six patients with necrotic cavitary pulmonary nodules are included. Clinical features, treatment and imaging details were presented. Results: All patients (n=6) with necrotic cavitary nodules were seropositive. All patients received leflunomide as conventional disease modifying anti-rheumatic drug (DMARD), while etanercept (n=1), infliximab (n=1), rituximab (n=1) and abatacept (n=3) as biological DMARD treatment. Except for one case (Case 2), all patients underwent bronchoscopy and nothing isolated from microbiological cultures. In the only biopsied case, the pathology was interpreted as a necrotizing rheumatoid nodule. In four patients, nodules were interpreted as in favor of the rheumatoid nodule. Mild-to-moderate FDG uptake was observed in five patients with PET-CT. In one patient (Case 6) without pulmonary nodules with methotrexate, new pulmonary nodules were developed, showed cavitation and progression after the transition to leflunomide. In another patient (Case 4), nodules developed under leflunomide were observed to cavitate after abatacept. In a patient (Case 1) receiving certolizumab, treatment was discontinued after nodules gain cavitary properties but even after those nodules tended to progress in size. Conclusion: It should be kept in mind that cavitary pulmonary nodules in patients with RA can be associated with the disease itself or with the conventional (especially leflunomide) or biological DMARD therapies.

Background Salivary flow rates (SFR) and oral health were known to be frequently impaired in Sjogren’s syndrome (SjS) due to chronic inflammation and destruction of the salivary glands. Ultrasonography (USG) of major salivary glands (SG-USG) is a non-invasive widely used tool to evaluate salivary glands in SjS. Objectives The aim of the study was to assess the relationships between SFRs, oral health and USG changes of major salivary glands in patients with primary SjS. Methods Fifty-nine SjS patients (F/M:57/2) with the mean age of 52.2±11.5 years. The duration of follow-up period of 9.±7.1 years fulfilling ACR-EULAR classification criteria (2002) were included. Major salivary glands (bilateral parotis and submandibular glands) were scored according to two different scoring systems which are Hocevar A.(0–48) and Milic VD. (0–12). Oral health was assessed by indices. Measurements of whole unstimulated and stimulated SFRs were carried out in patients between 9 a.m. and 10 a.m in the morning. Oral health related quality of life (OHRQoL) as a patient reported outcome measure was evaluated by using Oral health impact profile (OHIP-14). High scores indicated poor OHRQoL status. Pathologic findings in oral health (GM) and USG images (NI) were evaluated by two authors as double-blind. Results Unstimulated SFR (0,2±0,2 ml/min) was correlated with stimulated SFR (1,1±0,7 ml/min) in the whole group (r=0,8 p=0.000). Moderate correlations were seen between unstimulated and stimulated whole SFRs and scores of hypoechogenic areas in bilateral parotid and submandibular glands (p Conclusions Unstimulated and stimulated SFRs were found correlated with the structural changes of major salivary glands. Tooth loss and poor OHRQoL were shown in patients due to reduced salivary outputs. USG images of salivary glands could give insight to physicians about oral health and OHRQoL as outcome measure in patients with SjS. Disclosure of Interest None declared

Objectives In this study, we aimed to investigate the concordance of ultrasonographic remission with other remission criteria and to show the influence of non-inflammatory patient-induced factors such as depression, anxiety, fibromyalgia and fatigue on both clinical and ultrasonographic remission. Methods Fifty consecutive patients with clinical remission (DAS-28-ESR Patients were also assessed whether they met the Boolean and SDAI remission criteria. 28 joint grey scale (GS) and power Doppler (PD) ultrasonography were performed. Patients‘ depression and anxiety were assessed by The Hospital Anxiety and Depression Scale (HADS), and their fatigue was assessed by multidimensional Assessment of Fatigue (MAF) scores and patients’ fibromyalgia was assessed by widespread pain index (WPI) and symptom severity score (SS). Results Patients were divided into 4 groups according to different remission definitions by ultrasonography. (Group1: PD=0 and GS=0, Group2: PD=0 and GS ≥0, Group3: PD=1 or 0 and GS=1 or 0, Group4: PD=1 or 0 and GS ≥0). Although it is not statistically significant, the highest agreement with all the clinical remission criteria was found in the USG remission group 4 (table 1). Patients with ultrasonographic remissions at their first visit in 2011 were reevaluated with clinical remission criteria at the end of 5 years. The highest remission rates were found in patients with USG remission group 3 (DAS28 58%, Boolean 29%, SDAI 47%). There was no significant difference between fatigue, fibromyalgia, depression and anxiety measures between remission and non-remission in all USG remission groups. In contrast, depression (p Conclusions Clinical and ultrasonographic remission was found to be compatible in half of the patients. The compliance of the USG remission in Group 4 with the clinical remission definitions was good, and clinical remission continuity was higher in the group meeting the definition of group 3. In contrast the ultrasound remission, the high levels of depression and anxiety in patients without SDAI and Boolean remission suggest that non-inflammatory patient-derived measures have less influence on the ultrasound remission. Disclosure of Interest None declared

Background The number and morphology of telangiectases (T) have been studied in terms of severity and organ involvement in sytemic sclerosis (SSc). T are located more frequently on face and trunk than extremities. Objectives We aimed to evaluate the impact of the localisation of T on different skin areas in addition to number on disease severity of SSc. Methods SSc patients fulfilling ACR/EULAR classification criteria (2013) who had the manifestation T were included. The number of T were calculated by using telangiectasia score (TS) (Shah A., et al) and localisation was classified according to presence of T on extremities or not. Simultaneously; ealy, active and late scleroderma patterns (Cutolo et al.) were determined qualitatively and capillary number (CN) was calculated per linear mm at distal row quantitatively by using nail fold video-capillaroscopy (NVC) in all patients. Results In 113 (106 female) SSc patients with T; the mean age was 52±12, the duration of follow-up 57±62 months, Raynaud and non-Raynaud symptom 10±8 and 7±7 years. Limited cutaneous form was found to be in 77 (%68), ANA positivity in 102 (%90) ve anti-Scl70 positivity in 33 (%29) patients. In SSc patients with TS score ≥6 or extremity T; the duration of non-Raynaud symptom was found to be longer (p=0010 or 0,009), MRSS and activity scores were higher (p=0004 or 0012 and p=0010 or 0,009) and severity scores of general, peripheral vascular involvement and skin were higher (p=0022 or 0,014, p=0030 or 0025 and p=0006 or 0,02), digital ulcers and flexion contractures were more frequent (p=0008 or 0035 and p=0027 or 0,032), late NVC pattern was more frequent and CN was lower (p=0001 or 0003 and p=0001 or 0,007). When patients were classified in 3 groups according to TS and presence of extremity T, differences in terms of organ involvement, disease activity and severity scores and NVC findings were summarised in table 1. Conclusions Disease duration was shown to be long, disease activity and severity were high and NVC findings were severe in patients with high scores of TS and extremity T. In patients with lower TS the presence of T on extremities was found to be related to severe disease. The number and localisation of T was emphasised as they are easy to evaluate in clinical practice and may be useful in determining severe patients with SSc. Disclosure of Interest None declared

Background Ultrasonography (USG) of major salivary glands (SG-USG)is a non-invasive tool that has been used to evaluate salivary glands in primary and secondary Sjogren’s syndrome (SjS). Objectives We aimed to investigate relation between the ultrasonographic scoring of major salivary glands and systemic disease activity or salivary secretion in patients with primary SjS. Methods Seventy-five SjS patients (F/M:73/2) with the mean age of 52±12 and duration of follow-up period of 58±54 months fulfilling ACR-EULAR classification criteria (2002) were included. Disease activity indexes (Sjogren’s Syndrome Patients Reported Index (ESSPRI), Visual Analogue Scale (VAS), EULAR Sjogren’s Syndrome Disease Activity Index (ESSDAI)] were recorded. Simultaneously, sialometric evaluation of the salivary glands was performed. Major salivary glands (bilateral parotis and submandibular glands) were scored according to two different scoring systems [Hocevar A.(0–48) and Milic VD. (0–12)] and elastography was recorded as well. Results Demographics, clinical characteristics, disease activity indexes and SG-USG scores were summarised in table 1 and table 2. Forty-one (55%) and 45 (60%) patients had the cut-off values of ≥17 (Hocevar) and ≥6 (Milic USG). The patients with the scores of ≥17 (Hocevar) were found to have higher scores of ESSPRI-total (16±6 vs 13±7, p=0,045) and lower sialometry (4,6±4,7 vs 8,4±4,6 ml, p=0,002). Scores of Hocevar and Milic-USG were negatively correlated with sialometry (r=-,430, p=0001 and r=-,430, p=0,001). Hocevar, Milic and elastography-USG scores were shown to be higher in patients with sialometry of ≤1,5 ml (n=7)(28±3 vs 17±10, p=0,010, 8±1 vs 5±3, p=0006 and 9±1 vs 5±2, p=0,028) and anti-Ro positivity(n=24) (24±10 vs 13±8 7±3 vs 4±2, p Conclusions Hocevar scoring system of major salivary glands was found to be related to patient reported activity in SjS. USG scores were associated with reduced saliva secretion and anti-Ro positivity. Severe parotid involvement was shown to be related to anti-RO and La positivity. Evaluation of SG-USG including different scoring systems and elastography might reflect function of the salivary glands. Disclosure of Interest None declared

Background Lung involment is one of the extra-articular manifestations that is shown to be related to morbidity and mortality in Rheumatoid arthritis (RA). Objectives We evaluated the progression of lung involvement in RA patients receiving biological treatment. Methods Eighty RA patients fulfilling ACR/EULAR classification criteria (2010) receiving biologics who had high-resolution computerised tomography (HRCT) of chest within 6 months of respiratory symptoms (cough/dyspnea) and/or any pathology in chest radiography were included. Warrick score, evaluating alveolitis and fibrosis, was calculated in RA patients by using HRCT of chest. Results The demographics and clinical findings were summarised in table 1. In 29 RA patients with interstitial findings in HRCT of chest; 7 (24%) were regressed and 1 (4%) was progressed with biologic drugs. Findings of alveolitis and fibrosis were completely regressed in 2, only alveolitis component was completely regressed in 3 and partially in 2 patients. The patient who progressed had new findings of alveolitis (table 2). Twenty-one patients in whom Warrick scores did not change, 5 received rituximab (RTX) and 10 received TNF inhibitors (TNF-inh). The mean Warrick scores was improved after biologics (11,3±9 (3–30) vs 10,3±9 (0–30), p=0,035). The improvement in alveolitis scores was significant (2,1±1,6 vs 1,5±1,6, p=0,031) while fibrosis scores were not (9,2±7,7 vs 8,8±8). Initial and control Warrick scores were higher in RTX receivers (16±9 vs 9,2±8, p=0034 and 14,8±10,1 vs 8,4±8,1), but the improvement after biologics was not different. Conclusions This study revealed an improvement in alveolitis after biologic drugs in RA patients. Fibrosis was not found to be effected by therapy. Lung lesions were improved in both RTX and TNF-inh groups. Disclosure of Interest None declared

Background In patients with seronegative rheumatoid arthritis (RA) there is a difficulty to make the differential diagnosis with the spondyloarthropathies. Objectives To assess the presence of enthesitis in patients with seronegative RA in comparison with the healthy controls (HC), patients with seropositive RA and ankylosing spondylitis(AS). Methods In this cross-sectional study, seronegative and seropositive RA patients, who fulfilled the 2010 ACR/EULAR criteria, patients with AS and HC have been assessed by grey scale and power doppler ultrasonography for the presence of enthesopathy at the achilles tendon, plantar fascia, proximal patella, distal patella, quadriceps, tibialis anterior, triceps, common flexor and extensor tendons. Clinical assessment of the patient groups included demographic findings, health assessment questionnaire and DAS28. Results In our study, we recruited age and sex matched 27 seronegative RA, 19 healthy controls, 24 seropositive RA and 23 ankylosing spondylitis patients. We evaluated and analysed both right and left sides of the enthesis regions separately which have been indicated in the methods section. The mean DAS28, mean ESR and mean CRP of the patients with seronegative RA were 3.6±1.28, 32.2±21.2 and 12.37±27.77 respectively (table 1). Median of Madrid sonographic enthesitis index (MASEI) was 5 in patients with seronegative RA. 4 patients have severe scores (MASEI score ≥20). There were significant differences between seronegative RA and healthy controls (MASEI score:3), (p=0.014) but no differences has been observed between seronegative RA with seropositive RA (MASEI score:6) and anklosing spondylitis (MASEI score:7) in MASEI scores. In comparison, hypoechogenicity of quadriceps tendon (16 (29.6%) vs 6 (12.5%), p=0.037), bone erosion at the quadriceps tendon attachment (9 (16.6%) vs 0, p=0.003), calsification at achilles tendon (17 (31.4%) vs 6 (12.5%), p=0.023) have been observed more frequently in patients with seronegative RA than seropositive RA. Significantly higher number of patients with bone erosion at the common extansor tendon (26 (48.1%) vs 3 (6.5%), p= Conclusions We observed that enthesis involvement was not seldom in patients with seronegative RA. Furthermore there were also similar frequency of entesis involvement in seropositive patients with RA. The value of enthesis sites evaluation for the differential diagnosis of patients with seronegative RA should be further investigated and the assessment of enthesis sites in seronegative and seropositive RA patients can be important to detect active and chronic changes at the enthesis region. Disclosure of Interest None declared

Background TURKBIO registry is the Turkish version of Danish DANBIO rheumatologic database which has been established in 2011. Demographics and previous or current treatment with conventional (csDMARD) and targeted synthetic (tsDMARD), and biological DMARDs (bDMARDs) were collected. Objectives We aimed to investigate the efficacy and safety status of methotrexate (MTX) vs. leflunomide (LEF) use as a concomitant treatment with bDMARDs and tsDMARD in this registry. Methods Frequencies of achievement of remission or remission +low disease activity (LDA) at the 6th month of bDMARD or tsDMARD treatment were compared between patients who were on these medications with MTX vs. LEF as a concomitant treatment. Drug survival and switch rates of bDMARDs and tsDMARD treatments either with MTX or LEF were compared. The adverse effects with MTX and LEF concomitant use were evaluated as well. Results The study included 725 bDMARD or tsDMARD receiving RA patients from 8 participating centres of the TURKBIO registry. Of these patients, 462 (63.7%) were receiving concomitant MTX and 263 (36.3%) LEF. Demographic findings are given in the table 1. Achievement of remission and remission +LDA at the 6th month of bDMARD or tsDMARD initiation was similar in concomitant MTX vs LEF groups (51.4% vs. 53%, p=0.683). When each bDMARD and tsDMARD was evaluated separately, achievement of remission were again similar in MTX and LEF concomitant users (TNFi: 53% vs. 54%; ABA: 50% vs. 59%; RTX: 53% vs. 61%; TCZ: 42% vs. 35%; p>0.05 for all). For TOFA, although remission +LDA rate was numerically higher in MTX concomitant group than LEF group (42% vs. 21%), the difference was not statistically significant due to the smaller sample size of TOFA (n=33). The results were similar for all DMARD groups when remission was evaluated alone. Drug survival (17±12 vs. 16±11 months, p>0.05) and drug discontinuation (42,2 vs 38, p>0.05) rates of bDMARDs or tsDMARD were also not different in MTX vs. LEF concomitant users. Adverse effects rate (19.5% vs 20.5%, p>0.05) were similar between MTX vs. LEF concomitant users as well. Conclusions Achievement of remission or remission +LDA was not different with the concomitant use of MTX vs. LEF with any bDMARD or tsDMARD treatment in RA patients with a similar safety profile. LEF might be an alternative as a concomitant DMARD in MTX-intolerant RA patients initiating bDMARDs or tsDMARD. Disclosure of Interest None declared

Background Pulmonary involvement in rheumatoid arthritis (RA) is one of the extra-articular manifestations affecting morbidity and mortality during the course of the disease. Pulmonary function tests (PFTs) and thoracic high-resolution computerised tomography (HRCT) are the standard of care in the assessment of pulmonary involvement in RA. In this study, we aimed to compare the findings between self-reported questionnaires and HRCT to detect pulmonary abnormalities in RA patients. Methods Forty-two RA patients fulfilling ACR/EULAR classification criteria (2010) who had thoracic HRCT within 6 months of any symptom and/or any pathology on radiography of chest were included in the study. The patients were also assessed by modified Borg Scale, SF-36 Quality of Life Scale and Leicester Cough Questionnaire for the evaluation of respiratory symptoms. Results Demographics and clinical characteristics were summarised in table 1. Warrick score, assessing the severity and extent of alveloitis and fibrosis on thoracic HRCT, was evaluated in 15 patients with ILD (score range:4–28). DLCO values were lower in patients with Warrick score ≥1 (73±22% vs. 88±12%, p=0.019) while FVC were not found to be different. The findings of HRCT and self-reported questionnaires were summarised in table 2. Any relationship between self-reported questionnaires and Warrick scores was not detected. Presence of any parenchymal lesions was found to be associated with SF-36 total score (p=0,048). DLCO levels were found to be negatively correlated with SF-36 total scores (r=-0,470, p=0,006). Conclusions In this study, we could not show any relationship between self-reported questionnaires and thoracic HRCT findings, except a weak association of the presence of parenchymal lesions with SF-36 scores. Alveolitis and/or fibrosis on thoracic HRCT were found to be associated with lower DLCO. DLCO was shown to be negatively correlated with SF-36 scores. SF-36 might be included in the detection of pulmonary evaluation in RA patients. The relationship between thoracic HRCT findings and self-reported questionnaires in RA necessitates further studies. Disclosure of Interest None declared

Objective: We studied the occurrence of obstructive sleep apnoea (OSA) and pulmonary involvement in patients with scleroderma (SSc). Material and Methods: Sixty-two consecutive patients with SSc were enrolled into the study. Anthropometric parameters were recorded, and the patients underwent spirometry, carbonmonoxide diffusion capacity (DLCO) test, high-resolution computed tomography (HRCT), and overnight sleep recording with cardiorespiratory polygraphy. OSA diagnosis was based on an apnoea-hypopnoea index (AHI) >=15/h. Oxygen desaturation index (ODI) and time spent with saturation =1 based on the HRCT findings. Results: In all, 20 patients (32.3%) had OSA. Pulmonary involvement was found in 47 patients (75.8%) based on the HRCT, and in 41 (77.4%) based on the DLCO test, respectively, with no significant difference between SSc patients with vs without OSA. There was a negative linear correlation between Warrick score and FEV1, FVC, and DLCO values, respectively, but not with AHI and ODI. A negative linear relationship was found between DLCO and TS90% during sleep (r= -0.29; p=0.033). This association was independent of age, body-mass-index and AHI (p=0.007). Conclusion: Occurrence of OSA did not differ significantly between the SSc patients with vs without pulmonary involvement. However, a significant relationship was observed between DLCO% and TS90% during sleep. This relationship may contribute to the development of pulmonary hypertension and respiratory failure in patients with SSc. Whether treatment of OSA improves prognosis of these high-risk patients with SSc remains to be further explored.

Background Sjogren9s syndrome (SjS) is characterised by chronic autoimmune inflammation primarily affects the salivary and lacrimal glands. Recently, ultrasonography (USG) of major salivary glands (SG-USG) has been used to evaluate salivary glands in primary and secondary SjS. Objectives We aimed to investigate the association between the ultrasonographic scoring of major salivary glands and disease activity indexes in patientswith primary SjS. Methods Forty-two primary SjS patients fulfilling ACR-EULAR classification criteria (2002) were included. Disease activity indexes (Sjogren9s Syndrome Patients Reported Index (ESSPRI), Visual Analogue Scale (VAS), EULAR Sjogren9s Syndrome Disease Activity Index (ESSDAI)] were recorded. Major salivary glands (bilateral parotis and submandibular glands) were scored according to two different scoring system [Hocevar A. (0–48) ve Milic VD. (0–12)]. Results Demographics, clinical characteristics, disease activity indexes and SG-USG scores were summarised in table 1 and table 2. Twenty-four (57%) and25 (60%) patients had the cut-offvalues of ≥17 (Hocevar) and ≥6 (Milic USG).The patients with the scores of ≥17 (Hocevar)were found to have higher scores of ESSPRI-total (18±5 vs 14±5, p=0,01). Hocevar and Milic USG scores were shown to be higher in anti-Ro(+) SjS patients (25±10vs14±7and7±3vs4±2, p=0,01).USG scores were not found to be associated with the scores of ESSDAI, VAS and ESSPRI items. Conclusions Hocevar scoring system of major salivary glands was found to be related to patient reported activity in SjS. USG scores were associated with anti-Ro positivity. Evaluation of SG-USG might promote the diagnosis and follow-up of the SjS patients. Disclosure of Interest None declared

Background Gastrointestinal system (GI) is commonly involved in systemic sclerosis (SSc) beginning after early stages of disease. Objectives We aimed to investigate capillaroscopic findings among the SSc patients with GI involvement and malnutrition. Methods GI involvement was evaluated by UCLA SCTC GIT 2.0 questionnaire (Khanna D.) (7 multi-item; reflux, distension, soilage, diarrhea, social functioning, emotional wellbeing and constipation) in SSc patients ACR/EULAR classification criteria (2013). To report the nutrition status of the patients “malnutrition universal screening tool (MUST)” (sum of the scores of body mass index, weight loss in last 3–6 months and acute disease effect) scores were calculated. Simultaneously, nail fold video-capillaroscopy (NVC) was performed in all paatients to deterimine ealy, active late scleroderma patterns (Cutalo et al.). Results In 58 SSc patients (51 female); the mean age, duration of Raynaud9s, non-Raynaud symptom (year) and follow-up (month) were 46±13, 54±50, 10±9 and 7±7, respectively. Limited cutaneous form, positive ANA and anti-Scl70, telangiectases, dysphagia, digital ulcers, lung disease were found in 40 (71%), 48 (83%) and 21 (36%), 45 (78%), 39 (67%), 33 (57%), 23 (40%) in patients, respectively. Of the NVC patterns, early was found in 16 (28%), active was in 11 (19%), late was in 28 (48%) and normal in 3 (5%). The scores of disease activity, severity and GI were shown to be higher in patients with late NVC pattern (table-1). Of the patients with MUST score of >0 (n=10), 9 had late and 1 had early NVC pattern. Conclusions This SSc cohort predominantly had limited cutanous disease and vascular manifestations. In patients with late scleroderma pattern, severity of GI was higher similar to disease activity and severity. Undernutrition was frequently seen in patients with late pattern. NVC might be useful to predict the severity of GI and malnutrition and allow to direct the patients to required procedures earlier. Disclosure of Interest None declared

Background Severity of peripheral vascular involvement (PVI)is known as an important determinig cause of morbidity in sytemic sclerosis (SSc). Different vasodilating agents have been found to reduce severity and contribute to healing of digital ulcers (DU)in SSc. Objectives We aimed to evaluate the characteristics and capillaroscopic patterns of the patients with severe PVI under different vasodilator therapeutic regimens. Methods The patients were grouped as “severe PVI” if score of PVI is ≥2 (PVT=2,digital pitting scars; PVT=3, digital tip ulcerations and PVT=4, digital gangrene; Medsger) and “non-severe PVI” if score of PVI is ≤1 (PVI=0,no Raynaud9s; PVI=1, Raynaud9s requiring vasodilators). We included patients with severe PVI who received cyclic iloprost and bosentan and/or sildenafil and compared to non-severe PVI. Nail fold video-capillaroscopy (NVC)was assessed qualitatively (Cutalo et al., early, active and late patterns). Results Severe PVI group more frequently had diffuse cutaneous form, contractures, lung disease, anti-Scl70 positivity and high acute phase response and exposed to immunosuppressives (table-1). Scores of telangiectasia, skin, activity and severity were lower in non-severe group. NVC late pattern was frequent and early pattern was rare in severe PVI groups. Forty-one% (9/22) of patients received second oral agent for PVI. Monotherapy and combination groups had similar scores (table-2). Conclusions NVC late pattern was frequent in severe PVI group with long disease duration, exposed to intensive immunosuppresives and received specific vasodilators for PVI. Disease activity and severity were higher in severe PVI group. One third of the severe group required oral combination therapy for PVI. Monotherapy and combination groups were similar in terms of severity. NVC is a useful method to monitor digital ischemia and severe organ involvement in SSc. Disclosure of Interest None declared

Background In patients with seronegative rheumatoid arthritis (RA) there is a difficulty to make the differential diagnosis with the spondyloarthropathies. Objectives To assess the presence of enthesitis in patients with seronegative rheumatoid arthritis in comparison with the healthy controls, patients with seropositive rheumatoid arthritis and ankylosing spondylitis. Methods In this cross-sectional study, seronegative and seropositive rheumatoid arthritis patients, who fulfilled the 2010 ACR/EULAR criteria, patients with ankylosing spondylitis and healthy controls have been assessed by grey scale and power doppler ultrasonography for the presence of enthesopathy at the achilles, plantar fascia, proximal patella, distal patella, quadriceps, tibialis anterior, triceps, common flexor and extensor tendons. Clinical assessment of the patient groups included demographic findings, health assessment questionnaire and disease activity score. Results In our study, we recruited age and sex matched 27 seronegative RA, 17 healthy controls, 20 seropositive RA and 12 ankylosing spondylitis patients. We evaluated and analysed both right and left sides of the enthesis regions separately which have been indicated in the methods section. The mean DAS28, mean ESR and mean CRP of the patients with seronegative RA were 3.6±1.28, 32.2±21.2 and 12.37±27.77 respectively (Table 1). Median of Madrid sonographic enthesitis index (MASEI) was 5 in patients with seronegative RA. 4 patients have severe scores. There were significant differences between seronegative RA and healthy controls (3, p=0.014) but no differences has been observed between seronegative RA with seropositive RA (6) and anklosing spondylitis (7) in MASEI scores. In comparison, hypoechogenicity of quadriceps tendon (16 (29.6%) vs 1 (2.5%), p=0.001), bone erosion at the quadriceps tendon attachment (9 (16.6%) vs 0, p=0.007), hypoechogenicity of triseps (13 (24%) vs 7 (17.5%), p=0.049) have been observed more frequently in patients with seronegative RA than seropositive RA. Significantly higher number of patients with bone erosion at the distal patella (10 (41.6%) v 3 (5.5%), p= Conclusions We observed that enthesis involvement was not seldom in patients with seronegative RA. Furthermore there were also similar frequency of entesis involvement in seropositive patients with RA. The value of enthesis sites evaluationfor the differential diagnosis of patients with seronegative RA should be further investigated and the assessment of enthesis sites in seronegative and seropositive RA patients can be important to detect active and chronic changes at the enthesis region. Disclosure of Interest None declared

symptom but this was similarly reported in both patient groups (15/24 vs 29/42), as were buttock (7/24 vs 9/42), neck (9/24 vs 11/42), knee (5/ 24 vs 8/42), shoulder (5/24 vs 11/42), and foot (6/24 vs 7/42) pain. Crucially, eye inflammation (later diagnosed as uveitis) was reported as a first symptom for 39% (9/24) of uveitis patients. Importantly, hip pain (10/24 vs 10/42; P

Objectives To determine the association of nailfold videocapillaroscopy(NVC)findings and telangiectasia score with DU history and severity of peripheral vascular involvement(PVI) in Systemic Sclerosis(SSc). Methods Fifty-nine SSc patients fulfilling Leroy and Medsger criteria were evaluated including Telangiectasia Score(TS)(Shah AA et al. J Rheumatol 2010), Modifiye Rodnan Skin Score(MRSS), Valentine Activity Scale(VAS) and Medsger Severity Scale(SS). Qualitative(early, active and late patterns) and semiquantitative assessments [capillary number(CN), irregularly enlarged capillaries(IEC), giant capillaries(GC), capillary ramifications(CR), microhaemorrhages(H), capillary array disorganisation(CAD) and microangiopathy evolution score(MES)]. was performed by NVC(Sulli et al. Ann Rheum Dis 2008) Results The mean age of patients was 45.6 and 91,5% were females. The mean duration of Raynaud’s(RS), non-Raynaud symptoms(NRS), skin involvement(SI)(year) were 6.1±6.5, 3.1±2.0, 3.0±2.0 respectively. Of the patients 20(34%) were diffuse cutaneous,35(59%) were limited and 4(7%) were sine-scleroderma;13(22%) were anti-centromere(+) and 29(49%) were anti-Scl70(+). DU history (DU+) was present in 27(46%) and telangiectases were present in 34(58%). When we compare DU- and DU + groups, the mean score of CN was 1.4±0.7 vs 2.0±0.5*(p Conclusions DU history and severe PVI in SSc was associated with capillary loss and microangiopathy. ‘Early’ NVC pattern was very rare in patients with DU history and was not found in severe PVI. Severe PVI in males was more frequent than females. Telangiectasia scores were not found to be related to PVI. NVC may be a helpful method in the assessment of SSc patients for PVI prognosis, warranting prospective studies. Disclosure of Interest None Declared