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Objectives The aim was to study the clinical features of PMR/GCA and clinical predictors of treatment response during a 40-week follow-up period. Methods Clinical data on 77 patients with newly diagnosed PMR/GCA who were treated with oral glucocorticoids were gathered at baseline and during a 40-week follow-up period. A unilateral temporal artery biopsy (TAB) and 18F-fluorodeoxyglucose (18F-FDG) PET/CT were undertaken at diagnosis. In total, each patient was seen on five occasions (i.e. baseline and weeks 4, 16, 28 and 40). Treatment response was assessed by considering clinical evaluations and results of inflammatory markers. Results Of 77 patients [49 (63.6%) female; mean age 71.8 (8.0) years], 64 (83.1%) patients had pure PMR, 10 (13.0%) concomitant PMR and GCA, and 3 (3.9%) pure GCA. The patients reported that clinical symptoms, apart from scalp pain and duration of morning stiffness, improved significantly at week 4 and remained lower at week 40 compared with the relative frequencies at baseline. Besides, all components of physical examination showed significant improvement and remained lower at week 40 compared with the baseline. A complete response was seen in 68.7, 62.9, 44.1 and 33.3% of patients at weeks 4, 16, 28 and 40, respectively. Several clinical features, including female biological sex, younger age, fewer relapses and a lower level of baseline ESR, were significantly associated with a better treatment response. Treatment response during the follow-up period was independent of TAB results and fluorodeoxyglucose uptakes on 18F-FDG PET/CT at diagnosis. Conclusion Obtaining valid disease-specific outcome measures for evaluating treatment efficacy in PMR and GCA that can be applied universally is clearly an unmet clinical need. Trial registration ClinicalTrials.gov, https://clinicaltrials.gov, NCT02985424.

IntroductionFast-track clinics (FTC) have been introduced in different fields and have been reporting significant outcomes in terms of reducing mortality, morbidity, and financial costs. To date, scarce evidence is available for FTC specific for patients suspected of polymyalgia rheumatica (PMR). The primary aim of our paper is to provide an overview of the clinical impact of PMR on patients and the healthcare system by analysing multiple aspects: the median time from onset of symptoms to diagnosis and the burden of the disease both on the healthcare system costs and on patients’ quality of life (QoL). Secondarily, based on these data, we aim to discuss the potential advantages and feasibility of a PMR FTC in everyday clinical practice.Material and methodsWe performed a narrative non-systematic review (PRISMA protocol not followed) of PubMed and Medline (OVID interface) with the following MeSH terms: [polymyalgia rheumatica AND diagnosis OR diagnosis, delayed OR patient care OR early diagnosis OR length of stay OR costs OR healthcare system OR quality of life] or [polymyalgia rheumatica AND glucocorticoids AND side effects]. We decided to exclude every paper that did not report raw data in terms of diagnostic time or delay, hospitalization rate, socio-economic costs on the healthcare system, patients’ QoL, and glucocorticoids-related events in PMR patients. Papers focused primarily on giant cell arteritis patients with overlapping PMR were also excluded. Abstract archives of the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) congresses of the last 10 years were screened and included in the search if raw data were available. Each paper’s reference list was scanned for additional publications meeting this study’s aims. When papers reported data partially presented in previous articles, we opted to use the most recently published data.ResultsAccording to our literature review, a PMR FTC might lighten the burden of the disease. Nevertheless, its feasibility depends mostly on the resources of the national health system and of the territorial health district, which are heterogeneously limited. The usefulness of PMR FTCs depends on closer collaboration with the general practitioner because he/she is the first clinician to visit patients with PMR.ConclusionsPolymyalgia rheumatica fast-track clinics might lighten the burden of the disease. However, it has some limits that should carefully assessed in planning health policies.

The aim of the study was to identify the prevalence of newly diagnosed malignancies in patients with polymyalgia rheumatica (PMR) and giant cell arteritis (GCA), with the aid of 18F-FDG PET/CT scan compared to conventional imaging techniques: Chest X-ray (CXR) and abdominal ultrasound (US). Secondarily, to examine the relative diagnostic accuracy of these two imaging modalities for the detection of cancer. Eighty consecutive patients with newly diagnosed PMR, GCA, or concomitant PMR and GCA, were included and followed up for 40 weeks. All patients underwent an 18F-FDG PET/CT scan, CXR, and abdominal US at diagnosis. Imaging findings were dichotomously categorized into malignant or benign. Among 80 patients, three patients were diagnosed with seronegative rheumatoid arthritis and were excluded from the analysis. Of the remaining 77, 64 (83.1%) patients were diagnosed with pure PMR, 3 (3.9%) with pure GCA, and 10 (13.0%) with concomitant PMR and GCA. Five types of cancer that were more prevalent than the one-year prevalence of 1.2% among the background population were found in four (5.2%, 95%CI: 1.4&ndash, 12.8%) patients. CXR/abdominal US could detect the solid cancer in one patient, whereas 18F-FDG PET/CT could identify all four solid cancers. Furthermore, four (5.2%, 12.8%) cases of monoclonal gammopathy of undetermined significance (MGUS) were found. An increase in C reactive protein (CRP) implicated an increased risk for cancer of 2.4% (OR: 1.024, 95%CI: 1.001&ndash, 1.047, p = 0.041). 18F-FDG PET/CT can reveal occult cancers at an early stage with a high negative predictive value, and it is specifically beneficial in PMR/GCA patients with nonspecific symptoms.

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Rheumatoid arthritis (RA) is a systemic, autoimmune disease that present with intra-articular and extra-articular manifestations. Auditory system may be involved during the course of RA disease due to numbers of pathologies. The link between hearing impairment and RA has been discussed in the previous literature. In this study we provide an update on the clinical aspect of hearing impairment in RA. We suggest to test hearing in all newly diagnosed RA patients at diagnosis as well as regularly during the course of disease.

Background: Polymyalgia rheumatica (PMR)/Giant cell arteritis (GCA), common inflammatory diseases, are associated with increased risk of aortic stiffness, possibly due to an inflammatory process.1,2 Objectives: To evaluate the effect of steroid treatment on aortic stiffness in patients with PMR/GCA. Methods: This is an ongoing 1-year prospective cohort study. 37 consecutive patients with newly diagnosed PMR/GCA were included. Aortic pulse wave velocity (PWV) and aortic augmentation index normalized to heart rate of 75 beats per minute (AIx@75) were measured at baseline and subsequently at 1st and 4th months of treatment initiation with oral prednisolone. Results: Of 37 patients, 3 pts. were excluded from the study because of lack of interest or a change in the initial diagnosis. Of all included pts. 61.8% were female and mean age was 71 (69-74) years. At diagnosis, 24 pts. presented with pure PMR symptoms, 2 pts. with pure cranial GCA, 8 pts.with concurrent PMR and GCA. The mean of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) at baseline were 62.3±22.9 and 46.4±43.7, respectively. AIx@75 was significantly decreased after 4 months of treatment initiation (from 26.1±11.6 to 19.5 ±11.5, p=0.016). Though aortic PWV was decreased after 4 months of treatment initiation (from 12.3±2.4 to 11.6±2.4), the results was not statistically significant (p=0.070). We did not find any significant changes at 1st month, nor in aortic PWV neither in AIx@75. Conclusion: Steroid treatment may improve arterial stiffness in PMR/GCA patients due to suppression of the inflammatory process. However this is a time consuming effect and may not be seen as early as the first month. References: [1] Emamifar A, et al. Polymyalgia rheumatica and giant cell arteritis-three challenges-consequences of the vasculitis process, osteoporosis, and malignancy: A prospective cohort study protocol. Medicine (Baltimore). 2017;96(26):e7297. [2] Schillaci G, et al. Aortic stiffness is increased in polymyalgia rheumatica and improves after steroid treatment. Ann Rheum Dis 2012;71:1151-6. Disclosure of Interests: None declared

Background Poor adherence to the osteoporosis prophylaxis medications has been reported before, which may result in treatment failure.1 However findings of previous studies are controversial.1,2 Objectives To investigate the role of nurse-led telephone follow-up to increase the level of adherence to osteoporosis prophylaxis medications in patients with newly diagnosed Polymyalgia Rheumatica/Giant Cell Arteritis (PMR/GCA). Methods This is an ongoing 1-year prospective cohort study. 37 consecutive steroid treated patients with newly diagnosed PMR/GCA were included. Patients were seen by the physicians at baseline, 1st and 4th month, where they were interviewed about their compliance towards osteoporosis prophylaxis medications, i.e. Calcium/Vitamin D supplements and Bisphosphonates (if Tscore ≤−1), using a standardized questionnaire. Patients were therefore categorized as 100%, 50-100%, Results 85.3% and 75.8% of the patients were completely adherent to their osteoporosis medications at 1st and 4th months of treatment initiation, respectively. (figure 1) The difference between level of adherence to the osteoporosis medications at 1st (=week 4) and 4th month (=week 16) was not statistically significant. (P value:0.369). Decreased adherence in the patients was mainly due to forgetfulness. Conclusion Compared to the earlier findings we found a higher level of adherence in this group of patients. Nurse-led telephone follow up as well as educating the patients respecting the importance of the osteoporosis medications for preventing steroid related side effects, may enhance and subsequently maintain high level of adherence to the osteoporosis medications. Our findings are in line with our earlier study indicating a high level of adherence to the osteoporosis medications in PMR/GCA patients.2 References [1] Rossini M, et al. Determinants of adherence to osteoporosis treatment in clinical practice. Osteoporos Int. 2006;17:914-21. [2] Emamifar A, et al. Level of Adherence to Prophylactic Osteoporosis Medication amongst Patients with Polymyalgia Rheumatica and Giant Cell Arteritis: A Cross-Sectional Study. International Journal of Rheumatology. 2015;2015:783709. Disclosure of Interests None declared

Patient: Female, 78 Final Diagnosis: Pott’s disease Symptoms: Back pain • nausea • vomiting • weight loss Medication: — Clinical Procedure: MRI Specialty: Infectious Diseases Objective: Rare disease Background: Pott’s disease (PD) or spinal tuberculosis is a rare condition which accounts for less than 1% of total tuberculosis (TB) cases. The incidence of PD has recently increased in Europe and the United States, mainly due to immigration; however, it is still a rare diagnosis in Scandinavian countries, and if overlooked it might lead to significant neurologic complications. Case Report: A 78-year-old woman, originally from Eastern Europe, presented to the emergency department with a complaint of nausea, vomiting, weight loss, and severe back pain. On admission she was febrile and had leukocytosis and increased C-reactive protein. Initial spinal x-ray was performed and revealed osteolytic changes in the vertebral body of T11 and T12. Magnetic resonance imaging (MRI) of the spine illustrated spondylitis of T10, T11, and T12, with multiple paravertebral and epidural abscesses, which was suggestive of PD. Polymerase chain reaction (PCR) of the patient’s gastric fluid was positive for Mycobacterium tuberculosis (MT). Based on MRI and PCR findings, standard treatment for TB was initiated. Results of the spine biopsy and culture showed colonies of MT and confirmed the diagnosis afterwards. Due to the instability of the spine and severe and continuous pain, spine-stabilizing surgery was performed. Her TB was cured after nine months of treatment. Conclusions: PD is an important differential diagnosis of malignancy that should be diagnosed instantly. History of exposure to TB and classic radiologic finding can help make the diagnosis.

Background:Rheumatoid arthritis (RA) is a systemic, inflammatory disease that affects 1% of the population. The auditory system may be involved during the course of disease; however the association of RA and hearing impairment has not been clearly defined.Objective:The objective of this review is to evaluate published clinical reports related to hearing impairment in patients with RA. Furthermore, we discuss possible pathologies and associated factors as well as new treatment modalities.Method:A thorough literature search was performed using available databases including Pubmed, Embase, Cochrane and ComDisDome to cover all relative reports. The following keywords were used: hearing loss, hearing difficulties, hearing disorders, hearing impairment, sensorineural hearing loss, conductive hearing loss, mixed hearing loss, autoimmune hearing loss, drug ototoxicity, drug-induced hearing loss, hearing test, audiometry, auditory dysfunction and rheumatoid arthritis.Conclusion:Based on our review it can be postulated that patients with RA are at higher risk of hearing impairment compared to healthy subjects in their course of the disease. The hearing impairment in RA seems to be a multifactorial condition; however the mechanisms of injury, as well as the relative risk factors, are not completely clear. This review can aid to clarify this condition and is a guide for further evaluation. To the best of our knowledge, this is the first review of hearing impairment in RA.

Background: Patients with Rheumatoid Arthritis (RA) may present with various comorbidities resulting in worse treatment response.[1-2] Objectives: To investigate the impact of selected comorbid diseases on RA outcome with the aim of Disease Activity Score in 28 joints-C-Reactive Protein (DAS28-CRP). Methods: All our RA patients were included in this study. Patients’ demographics, serology results and DAS28-CRP at the time of diagnosis and after 4 months of treatment initiation were collected. Patients’ electronic hospital records were evaluated for a positive history of thyroid diseases, Diabetes Mellitus (DM), primary hyperparathyroidism, vitamin B12 deficiency and presence of other diagnosed autoimmune diseases. Results: 1035 RA patients were included. 63.4% were female, mean of age 67.1 years, mean of disease duration 9.6 years, 58.6% rheumatoid factor positive and 51.3% anti-cyclic citrullinated peptide positive. The observed prevalence of thyroid diseases was 11.8%, DM 10.4%, primary hyperparathyroidism 2.8%, vitamin B12 deficiency 5.8%, and other diagnosed autoimmune diseases 1.6%. There were significant associations between presence of thyroid diseases and female gender (p

To investigate the impact of comorbid diseases on rheumatoid arthritis (RA) outcome. All patients diagnosed with RA since 2006, who were registered in our local Danbio registry, were included in this cohort study. Patients' demographics, serology results, and Disease Activity Score in 28 joints-C-reactive protein (DAS28-CRP) at the time of diagnosis and after 4 months of treatment initiation were collected. Patients' electronic hospital records were evaluated for a positive history of thyroid diseases, diabetes mellitus, primary hyperparathyroidism, vitamin B12 deficiency, and the presence of other diagnosed autoimmune diseases. 1035 RA patients were included. The observed prevalence of thyroid diseases was 11.8%, DM 10.4%, primary hyperparathyroidism 2.8%, vitamin B12 deficiency 5.8%, and other diagnosed autoimmune diseases 1.6%. There were significant associations between presence of thyroid diseases and female gender (P < .001); DM and greater age (P < .001); primary hyperparathyroidism and longer disease duration (P = .002); other diagnosed autoimmune diseases and antinuclear antibody positivity (P < .001). RA patients with thyroid diseases (P = .001) and other comorbid autoimmune diseases (P < .001) had significantly poorer initial response to the RA treatment compared to patients with isolated RA. Univariate analyses revealed that age, the presence of thyroid diseases, the presence of other diagnosed autoimmune diseases and DAS28-CRP at the time of diagnosis were significantly associated with DDAS28-CRP. Additionally, multivariate analysis demonstrated that DDAS28-CRP deterioration was significantly correlated to the presence of thyroid diseases (unstandardized regression coefficient (standard error); 0.188(0.088), P = .030) and the presence of other diagnosed autoimmune diseases (-0.537 (0.208),P = .010). RA patients are at increased risk of specific comorbidities with possible impact on the treatment outcome. To improve this situation, periodic assessment of comorbidities should be considered.

Background Much effort has been made to improve the efficiency of health care system by delivering cost-effective, high-quality care.Nurse staffing9s contribution to daily practice plays a significant role to reach this goal.[1] Objectives To elucidate the differences between ratios of nurse/physician consultation as well as physician efficiency index (PEI) of senior rheumatologists and junior physicians in rheumatology residency training regarding patients with Rheumatoid Arthritis (RA).In addition, to delineate the correlation of physician postgraduate experience and PEI. Methods The mean intervals between standard consultation by a physician or nurse for all senior rheumatologists and junior physicians as well as nurse/physician visits ratio and PEI (= nurse/physician visits ratio * mean interval), regrading RA patients seen during Nov 2013–2015, were calculated. Multiple linear regression analysis was performed to delineate the relationship between physician postgraduate experience and PEI. To monitor treatment outcome, Disease Activity Score in 28 joints-C-reactive Protein (DAS28-CRP) and Health Assessment Questionnaire (HAQ) were consecutively measured three times: first at physician consultation, second at following nurse consultation and third either at a nurse or physician consultation. Results 3699 visits, belonged to 672 RA patients (64.1% female, the mean of age 64.9±14.1 and DAS28 at baseline 4.5±1.2), were included. There was a significant difference between the nurse/physician visits ratios of senior rheumatologists and junior physicians (P=0.01). Additionally, the mean PEI of senior rheumatologists was significantly higher than of junior physicians (P=0.04) (Table 1). A positive correlation was found between physician postgraduate experience and PEI adjusted for DAS28 at baseline and number of patients for each physician (Regression coefficient (95% Confidence Interval): 5.427 (1.068–9.787), P=0.022). DAS28 and HAQ score were significantly decreased if physician visits were followed by nurse visits (P=0.004 for DAS28 and P=0.025 for HAQ) (Fig.1), indicating a good treatment outcome at nurse consultations. Conclusions Junior physicians should be supervised to delegate responsibilities to nurse staffing. So, entire department operates more efficient, leading to prevent extra expenses (due to the differences in yearly salary of physicians and nurses). Quality of care should be monitored continuously by markers of disease activity and CRP. References Dall TM,et al.The economic value of professional nursing.Med Care2009;47:97–104. Disclosure of Interest None declared

Background Patients with Rheumatoid Arthritis (RA) are at increased risk of Diabetes Mellitus (DM) probably due to immune system activation or RA treatment with steroids.[1] However the pathology of DM in RA is not fully understood. Objectives To define the prevalence of DM in our RA patients population. Furthermore, to clarify the role of steroid treatment to induce DM in the RA patients. Methods All patients with diagnosis of RA who were registered in Danish Danbio Registry at time of study, Nov 2016, were included. To find the concurrent DM, patients9 medical records including past medical history and lab tests (Hemoglobin A1c and Blood Sugar) were reviewed. In addition, year of DM as well as RA diagnoses were extracted from Fyns Diabetes Database and Danbio respectively to the extent that data were available. Patients9 drug histories were searched for information about steroid treatment if diagnosis of RA was made prior to diagnosis of DM. Results Of 1035 patients with diagnosis of RA, 104 (10%) patients had DM. Of 104 RA patients with DM, data regarding the year of diagnosis for both RA and DM was found in 55 patients which of them 15 patients were diagnosed with RA before DM, one patient was diagnosed with both DM and RA at the same year and 39 patients were diagnosed with RA after DM. However, only one patient, of those who were firstly diagnosed with RA, was prescribed prednisolone during the time period between diagnoses of RA and thereafter DM. Of 15 patients with prior diagnosis of RA to DM, 13 patients were diagnosed according to 1987 classification criteria (Old) for RA and 2 patients were diagnosed according to 2010 classification criteria (New). Out of 39 patients where DM was diagnosed before RA, 10 patients was diagnosed based on the old criteria and 29 patients was diagnosed based on the new RA criteria [Fig 1A and 1B]. Patients with firstly diagnosed DM were more often diagnosed according to the new RA criteria and, on the contrary, patients with latterly diagnosed DM were more often diagnosed with old RA criteria (p Conclusions The prevalence of DM in this RA population (10%) was about twice of Danish population (5.7%). The role of steroid treatment in which to what extent increases the risk of DM is not clear, however in this study it was negligible, why we propose that the pathology of DM in RA patients most importantly deals with the role of immune system activation namely Tumor Necrosis Factor alpha and not the treatment modality i.e. steroids. References Jiang P, Li H, Li X. Diabetes mellitus risk factors in rheumatoid arthritis: a systematic review and meta-analysis. Clin Exp Rheumatol 2015;33:115–21. Acknowledgements We thank Mrs. Maryam Mousavi for her contribution to data collection. Disclosure of Interest None declared

INTRODUCTION: Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are common inflammatory conditions. The diagnosis of PMR/GCA poses many challenges since there are no specific diagnostic tests. Recent literature emphasizes the ability of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) to assess global disease activity in inflammatory diseases. 18F-FDG PET/CT may lead to the diagnosis at an earlier stage than conventional imaging and may also assess response to therapy. With respect to the management of PMR/GCA, there are 3 significant areas of concern as follows: vasculitis process/vascular stiffness, malignancy, and osteoporosis.METHODS AND ANALYSIS: All patients with suspected PMR/GCR referred to the Rheumatology section of Medicine Department at Svendborg Hospital, Denmark. The 4 separate studies in the current protocol focus on: the association of clinical picture of PMR/GCA with PET findings; the validity of 18F-FDG PET/CT scan for diagnosis of PMR/GCA compared with temporal artery biopsy; the prevalence of newly diagnosed malignancies in patients with PMR/GCA, or PMR-like syndrome, with the focus on diagnostic accuracy of 18F-FDG PET/CT scan compared with conventional workup (ie, chest X-ray/abdominal ultrasound); and the impact of disease process, and also steroid treatment on bone mineral density, body composition, and vasculitis/vascular stiffness in PMR/GCA patients.ETHICS AND DISSEMINATION: The study has been approved by the Regional Ethics Committee of the Region of Southern Denmark (identification number: S-20160098) and Danish Data Protection Agency (J.nr 16/40522). Results of the study will be disseminated via publications in peer-reviewed journals, and presentation at national and international conferences.

Background Fatigue is a common symptom in patients suffering from inflammatory rheumatic diseases. Several patients still present with fatigue, although they are well treated with anti TNF-therapy (1). Objectives To investigate disease-related aspects of fatigue in patients with inflammatory rheumatic diseases using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) with the aim later to develop methods to improve the patients quality of life in a more specific way. Methods All patients with inflammatory diseases including Rheumatoid Arthritis (38) and Spondyloarthropathy (13) and Psoriatic arthritis (2) treated with Intravenous biologic from 15.10 until 31.12.16 were invited to fill out the FACIT-F questionnaire during intravenous (IV) infusion of the drugs in the rheumatology outpatient clinic. Furthermore hemoglobin and disease activity score were extracted from patients electronic records. Results Of 72 patients, 53 patients completed the questionnaire. 5 patients did not want to participate. In 11 patients treatment was discontinued during the study and 3 patients were not able to answer the questions. Patients with a fatigue score of Conclusions Our results demonstrated that patients with a fatigue score of >30 had different challenges mentioned in the fatigue questionnaire. In addition, patients who experience fatigue at time of diagnosis, they often remain fatigue, provoking the thought that fatigue is not correlated with inflammatory joint disease. Maybe more explorative questions about fatigue at the consultation could be a part of improving the patients9quality of life. References Druce KL, et al. Most patients who reach disease remission following anti-TNF therapy continue to report fatigue: results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis. Rheumatology (Oxford). 2016;55:1786–1790. Webster K, Cella D, Yost K. The Functional Assessment of Chronic Illness Therapy (FACIT) Measurement System: properties, applications, and interpretation. Health Qual Life Outcomes 2003;1:79. Disclosure of Interest None declared

Background Rheumatoid Arthritis (RA) should be treated instantly to prevent further joint destruction. The first few months after treatment initiation are critical for long-term treatment outcome.[1]Patients with RA are at increased risk of thyroid disease with direct effect on initial treatment response.[2] Objectives To define the prevalence of thyroid disease among RA patients as well as to evaluate the correlation between presence of thyroid disease in RA patients and initial treatment response. Methods All RA patients who were registered in the local part of Danish Danbio registry were included in this study. Patients9 demographic data, serology results including rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (anti-ccp) as well as disease activity score in 28 joints-C-reactive protein (DAS28-CRP) at the time of diagnosis and after 4 months (±1–2 months) of treatment initiation were extracted. ΔDAS28 was calculated as follows: DAS28 at the time of diagnosis – DAS28 after 4 months (±1–2 months) of treatment initiation. Patients9 electronic hospital records including laboratory results were reviewed to reveal if they had been diagnosed with thyroid disease. Results 1035 patients were included in the study (Table 1). Prevalence of thyroid disease was 11.8% (122/1035). Multiple linear regression analysis showed a negative correlation between ΔDAS28 and presence of thyroid disease adjusted for age, gender, disease duration, RF, anti-ccp and DAS28 at the time of diagnosis (Regression coefficient (95% Confidence Interval): -0,157 (-0.312 to -0.002), P=0.047) (Table 2). RA patients with thyroid disease had significantly poorer initial response to RA treatment compared to patients with isolated RA after 4 months of treatment (P=0.002). Conclusions Presence of thyroid disease in RA patients worsens initial treatment response and is suggestive of poor long-term prognosis. The authors propose routine measurement of serum thyroid stimulating hormone (TSH) in all RA patients at the time of diagnosis and with yearly interval. References Smolen JS, Aletaha D, McInnes IB. Rheumatoid arthritis. Lancet 2016;388:2023–2038. doi: 10.1016/S0140–6736(16)30173–8. Joshi P, Agarwal A, Vyas S, et al. Prevalence of hypothyroidism in rheumatoid arthritis and its correlation with disease activity. Trop Doct 2017;47:6–10. Acknowledgements We thank Mrs. Maryam Mousavi for her contribution to data collection. Disclosure of Interest None declared

Background Patients with Rheumatoid Arthritis (RA) are at increased risk of different comorbidities which may affect long-term prognosis.[1] Primary hyperparathyroidism (PHP) is a metabolic disorder of one or more of the parathyroid glands with a prevalence of 1–7 per 1000 adults.[2] Objectives To define the prevalence of PHP in patients with RA. Methods All RA patients who were registered in the local part of Danish Danbio registry were included in this study. Patients9demographic data and serology results (rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (anti-ccp)) were extracted from Danbio. Patients9 electronic hospital records including laboratory results (Parathyroid hormone (PTH) and calcium levels) were reviewed to reveal if they had been diagnosed with PHP as well. Results 1035 RA patients were included in this study [table 1]. Prevalence of PHP was 2.8% (29/1035). RA Patients with PHP had significant longer disease duration compared to patients with isolated RA (p=0.003). There was no significant difference between RA patients with and without PHP with respect to age, gender, RF and anti-ccp positivity (Table 1). Conclusions Clinicians should pay special attention to higher prevalence of PHP among RA patients compared to the general population. Presence of PHP in RA patients may aggravate the effect of RA on bones and joints by means of interaction with cytokines and inflammatory markers involved in RA. Concurrent PHP can be diagnosed at early stage by testing PTH and calcium levels which minimize the future morbidities e.g. fracture due to osteoporosis. References Dougados M, Soubrier M, Antunez A, et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA). Ann Rheum Dis 2014;73:62–8. Yeh MW, Ituarte PH, Zhou HC, et al. Incidence and prevalence of primary hyperparathyroidism in a racially mixed population. J Clin Endocrinol Metab 2013;98:1122–9. Acknowledgements We thank Mrs. Maryam Mousavi for her contribution to data collection. Disclosure of Interest None declared

Background Disease Activity Score in 28 Joints (DAS28) is a scoring system to evaluate disease activity and treatment response in rheumatoid arthritis (RA). A DAS28 score of greater than 3.2 is a well-described limit for treatment intensification; however, the reliability of DAS28 might be overestimated. Objective The aim of this study was to evaluate the reliability of DAS28 in RA, especially focusing on a subgroup of patients with a DAS28 score of greater than 3.2. Methods Data from RA patients registered in the local part of Danish DANBIO Registry were collected in May 2015. Patients were categorized into 2 groups: First, those with DAS28 >3.2 with at least one swollen joint (SJ) or elevated C-reactive protein (CRP) ("objective group"), and second, patients with a DAS28 >3.2 who had no SJ, and CRP values were within the reference range ("subjective group"). Disease Activity Score in 28 Joints, Clinical Disease Activity Index, and Health Assessment Questionnaire scores were calculated for each group. We defined new score, DAS28 subjective, to focus on subjective parameters. Results Two hundred thirty patients were included; 198 (86.1%) and 32 (13.9%) patients were in the objective and subjective groups, respectively. Patients in the subjective group had lower mean values of DAS28 (P < 0.001) and Evaluator Global Assessment (P < 0.001) with less common immunoglobulin M rheumatoid factor (P < 0.001) and anti-cyclic citrullinated peptide positivity (P = 0.02) and contrarily higher mean values of tender joints (P = 0.04) and DAS28 based on subjective parameters (P = 0.003) compared with the objective group. Conclusions Rheumatoid arthritis scoring systems should be used cautiously in patients who are considered for treatment intensification. Patients with central sensitization and psychological problems and those with false-positive diagnosis of RA are at high risk of overtreatment.

Background: Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is a rare, but well-defined syndrome comprising polyarthritis with symmetrical synovitis of the small joints in hands and feet accompanied by marked pitting edema. It is often considered a paraneoplastic syndrome, but here we report a case with F-18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) findings of polymyalgia rheumatica (PMR) in a patient with RS3PE and suspected of paraneoplastic syndrome.Objectives: To briefly report the potential of FDG-PET/CT in rheumatic settings.Methods: An 83-year-old male with a history of prostate adenocarcinoma simultaneously with RS3PE presented with pain and stiffness of the shoulder and hip girdles to the department of rheumatology. He was anemic and had hypersedimentation of 106. He also complained of sore and swollen hands compatible with RS3PE. The patient had a previous course of RS3PE, presented as a paraneoplastic syndrome, together with his prostate cancer one year earlier, which resolved when the prostatic cancer was in remission. FDG-PET/CT was performed due to suspicion of repeat paraneoplastic syndrome.Results: FDG-PET/CT findings showed no evidence of malignant disease. There was diffusely increased FDG in soft tissue around the shoulders and hips and FDG-positive axillary lymph nodes consistent with PMR.Conclusions: RS3PE and PMR may belong to the same clinical entity. FDG-PET/CT has a potential role in the management of PMR as well as other rheumatic diseases.

Background/Purpose: The threshold for reporting of C-reactive protein (CRP) differs from laboratory to laboratory. Moreover, CRP values are affected by the intra individual biological variability.[1] With respect to disease activity score in 28 joints (DAS28) and Rheumatoid Arthritis (RA), precise threshold for reporting CRP is important due to the direct effects of CRP on calculating DAS28, patient classification and subsequent treatment decisions[2] Methods: This study consists of two sections: a theoretical consideration discussing the performance of CRP in calculating DAS28 with regard to the biological variation and reporting limit for CRP and a cross sectional study of all RA patients from our department (n=876) applying our theoretical results. In the second section, we calculate DAS28 twice with actual CRP and CRP=9, the latter to elucidate the positive consequences of changing the lower reporting limit of CRP from

Objective.To evaluate the utility and impact of using a declination form in the context of an influenza immunization program for healthcare workers.Methods.A combined form for documentation of vaccination consent, medical contraindication(s) for vaccination, or vaccination declination was used during the 2006-2007 influenza season in a healthcare system employing approximately 9,200 nonphysician employees in 3 hospitals; a skilled nursing care facility; a large, multisite, faculty-practice plan; and an administrative building. Responses were entered into a database that contained files from human resources departments, which allowed correlation with job category and work location.Results.The overall levels of influenza vaccination coverage of employees increased from 43% (3,892 of 9,050) during the 2005-2006 season to 66.5% (6,123 of 9,214) during the 2006-2007 season. Of 9,214 employees, 1,898 (20.6%) signed the declination statement. Among the occupation groups, nurses had the lowest rate of declining vaccination (13.2% [393 of 2,970]; P < .0001), followed by pharmacy personnel (18.1% [40 of 221]), ancillary personnel with frequent patient contact (21.9% [169 of 771), and all others (24.7% [1,296 of 5,252]). Among the employees who declined vaccination, nurses were the least likely to select the reasons “afraid of needles” (3.8% [15 of 393], vs. 9.1% [137 of 1,505] for all other groups; P < .001) and “fear of getting influenza from the vaccine” (13.5% [53 of 393], vs. 20.5% [309 of 1,505]; P = .002). Seven pregnant nurses had been advised by their obstetricians to avoid vaccination. When declination of influenza vaccination was analyzed by age, 16% of personnel (797 of 4,980) 50 years of age and older declined to be vaccinated, compared with 26% of personnel (1,101 of 4,234) younger than 50 years of age {P < .0001).Conclusions.Implementing use of the declination form during the 2006-2007 influenza season was one of several measures that led to a 55% increase in the acceptance of influenza vaccination by healthcare workers in our healthcare system. Although we cannot determine to what degree use of the declination form contributed to the increased rate of vaccination, use of this form helped the vaccination program assess the reasons for declination and will help to focus future vaccination campaigns.

Patient: Male, 83 Final Diagnosis: Remitting seronegative symmetrical synovitis with pitting edema Symptoms: Morning stiffness • pitting edema of the hands • shoulder and hip pain Medication: — Clinical Procedure: 18FDG PET/CT Specialty: Rheumatology Objective: Rare disease Background: Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is a rare condition that occurs in elderly individuals. It can present alone or in association with various rheumatic or malignant diseases. Case Report: An 83-year-old man presented with anemia, hyper-sedimentation, and pitting edema of the back of the hands. The patient complained of pain and stiffness of the shoulder and hip girdles, especially in the morning. He was previously diagnosed with adenocarcinoma of the prostate. After 3 years of watchful waiting, treatment with goserelin, a gonadotropin releasing hormone agonist, was started, when PSA had increased to 67.9 µg/l. About 1 year before the cancer treatment, the patient also presented with sore and swollen hands, compatible with RS3PE, which remitted after a few months of prostatic cancer treatment. Thorough laboratory evaluation was performed upon admission to the Rheumatology Department and he was referred for FDG PET/CT on suspicion of metastases of the previously diagnosed prostatic cancer. PET/CT imaging revealed increased FDG up-take in the soft tissues around the shoulders and hips, but no evidence of bone metastasis or other malignant findings. A diagnosis of polymyalgia rheumatica (PMR) together with RS3PE syndrome was made and treatment with prednisolone 15 mg/d was started, which resulted in rapid resolution of the symptoms. Conclusions: Presence of RS3PE in relation with PMR and prostatic cancer in our patient suggests a common trigger factor. To the best of our knowledge, this is the first report of a case of RS3PE that presented twice with 2 different diagnoses in the same patient.

Vibrio vulnificus is a rare but potential fatal bacterium that can cause severe infections. Wound infections, primary sepsis and gastroenteritis are the most common clinical features. Septic arthritis caused by V. vulnificus is an atypical presentation that has been reported in only two case reports; however, it has not been previously noted in Denmark. The authors report a case of septic arthritis caused by V. vulnificus in an immunocompromised patient. The disease progressed to severe sepsis and subsequent death within 10 h of admission.

Rheumatic diseases (RD) and malignancies may be connected to each other in different ways. It has previously been shown, that RD can be a primary manifestation of an underlying cancer as a paraneoplastic syndrome (PNS). RD are related with increased incidence of different malignancies due to the characteristic of the disease or as a result of drug therapy, for instance immunosuppressive agents and tumor necrosis factor inhibitors .

Dislocation of the hip is a critical injury that results from high-energy trauma. This paper describes a case of posterior dislocation of the right hip in a 35-year-old woman with associated ipsilateral femoral head fracture. Initial treatment included reduction of the right hip through posterior approach and fixation of the femoral head fracture with three absorbable screws. After 15-month follow-up, a full range of motion has been achieved and there are no signs of avascular necrosis, hip instability, or limping. The authors describe their method of surgery.

Objective. To estimate level of adherence to oral calcium and vitamin D supplementation as well as bisphosphonate amongst patients with PMR and GCA treated with glucocorticoids.Method. A total of 138 patients with the diagnosis of PMR and/or GCA registered in our department in December 2013. In this cross-sectional study we interviewed all the patients to measure level of adherence to calcium and vitamin D, as well as bisphosphonates.Results. Out of the 118 included patients, 88.9% of them were adherent to their prescription. Only 2 patients (1.7%) did not take calcium and vitamin D at all and 10 patients (8.5%) took their medication infrequently, 9 and 1 out of 10 patients took the medication 50–100% of the time and less than 50% of the prescribed dose, respectively. Sixty-one patients received additional treatment with bisphosphonate and 96.6% were adherent to this therapy. The remaining 3.4% of the patients did not take the medication at all. Forgetfulness, adverse side effects, and lack of understanding of treatment benefits were the most significant causes for nonadherence to calcium and vitamin D.Conclusions. Contrary to what we expected this study found that adherence to osteoporosis preventive medication in patients with PMR and GCA was high.

William M. Ord described the first case of muscle weakness with hypothyroidism in 1880 and subsequently it has been reported in several cases . Hypothyroid induced myositis is an inflammatory myopathy characterized by musculoskeletal symptoms which can be confirmed through increased serum level of muscle enzymes such as creatine kinase (CK) (up to 10 times normal), nonspecific electromyographic (EMG) abnormalities and pathological findings in muscle biopsies . Frequent symptoms include fatigue, proximal muscle weakness, myalgia, tenderness, and stiffness . Necrosis, inflammatory infiltrates, type II fiber atrophy, increased numbers of internal nuclei, and “core-like” structures in type I fibers are common findings in muscle biopsies [3, . Treatment of these patients consists of administration of thyroid hormone and in some cases also corticosteroids. It can take several months for the muscle symptoms to resolve [1, .

To determine the prevalence of thyroid disorders among newly diagnosed rheumatoid arthritis (RA) patients and evaluate the association between clinical characteristics of RA and thyroid disorders, and also initial treatment response in the RA patients with thyroid disorders. Newly diagnosed, adult RA patients who were diagnosed according to the new 2010 American College of Rheumatology/European League Against Rheumatism criteria since January 1, 2010, were included. Patients’ demographic data, serology results including immunoglobulin M rheumatoid factor (IgM RF), anticyclic citrullinated peptide antibody (anti-CCP), and antinuclear antibody (ANA), and also disease activity score in 28 joints-C-reactive protein at the time of diagnosis and after 4 months (±1–2 months) of treatment initiation were extracted from Danish Danbio Registry. Patients’ electronic hospital records for the past 10 years were reviewed to reveal if they had been diagnosed with thyroid disorders or they had abnormal thyroid test. In all, 439 patients were included, female 60.1%, mean age 64.6 ± 15.0 years and disease duration 2.6 ± 1.7 years. Prevalence of thyroid disorders was 69/439 (15.7%) and hypothyroidism was the most frequent disorder (30.4%). The presence of thyroid disorders among RA patients was significantly associated with female sex (P

Our team surveyed a group of pharmacy directors to learn about their experiences with pharmacy consultants so that the directors might be able to use their consulting resources in a more effective manner.In May 2012, the University HealthSystem Consortium (UHC) Pharmacy Council Financial Performance Committee developed an electronic survey that collectively measured the characteristics, goals, and methodology of historical pharmacy consultant engagements and level of satisfaction. After e-mailing the initial electronic survey, we conducted follow-up telephone interviews with respondents from July through November 2012. These interviews were designed to include questions about expected outcomes, recommendations for evaluation processes, timelines for implementing the recommendations, consultants' expenses, and insights gained.A total of 23 pharmacy directors responded to the initial electronic survey; their organizations had engaged at least one consultant within the previous 5 years. Data were collected for 28 consultant engagements. Subsequent telephone interviews were conducted with 20 of the 23 pharmacy directors (87%) who completed the initial electronic survey, accounting for 25 of the 28 consultant engagements (89%).Cost reduction along with revenue enhancement was most often the focus of these engagements. These engagements were also mainly within the scope of an organization-wide effort initiated by the executive board or executive team. Consultant experiences varied greatly in terms of (1) the degree to which assistance was provided to the organization, (2) benchmarking methodologies and resources, and (3) timelines for implementing the consultants' recommendations. In general, most respondents rated their consultant experience as positive and were able to provide "pearls of wisdom" or lessons learned.

Disease Activity Score in 28 joints (DAS28) is commonly used to evaluate disease activity of rheumatoid arthritis (RA) and is a guide to treatment decision. The aim of this study was to evaluate the impact of lower reporting limit for C-reactive protein (CRP), with respect to intraindividual biological variability, on the calculation of DAS28 and subsequent patient classification. This study consists of 2 sections: a theoretical consideration discussing the performance of CRP in calculating DAS28 taking intraindividual biological variation and lower reporting limit for CRP into account and a cross-sectional study of RA patients applying our theoretical results. Therefore, we calculated DAS28 twice, with the actual CRP values and CRP= 9 mg/L, the latter to elucidate the positive effects of reducing the lower reporting limit of CRP from

Background Rheumatoid arthritis (RA) is a chronic inflammatory polyarthritis with a prevalence of 0.5–1% of general population.[1] Various comorbidities can complicate the course of the disease and have direct effects on the long-term prognosis and management of RA.[2] Previous studies showed that there is an increased prevalence of thyroid disease (TD) among RA patients, probably due to autoimmunity; however the association of RA disease characteristic and TD has not been evaluated before.[3] Objectives To determine the association between TD and RA and reveal the prevalence of TD among RA patients. Methods All patients diagnosed with RA since 1st of January 2010 were included in this cross sectional study. Patients9 demographic data (age, sex, year of diagnosis), serology test results including rheumatoid factor (RF), anti-cyclic citrullinated peptide antibody (anti-ccp) and antinuclear antibody (ANA) as well as disease activity score in 28 joints (DAS28) at the time of diagnosis and after 4 months (±1–2 months) of treatment were extracted in December 2015. Patients9 previous medical history as well as medications and laboratory tests were evaluated to find out if the patients have been diagnosed with thyroid disease as well. Patients with subclinical thyroid diseases were also considered to perform statistical analysis. Chi-square test and t-test were used to compare different variables in patients with/without TD. Results Of 439 included patients 60.14% were female. The mean of age and disease duration were 64.64±15.03 and 2.59±1.66 years respectively. Prevalence of TD was 69/439 (15.7%). The mean of ΔDAS28 in patients with simultaneous TD and RA was 1.0±1.4 and in patients with isolated RA 1.5±1.4 (P Conclusions Considering the higher prevalence of TD among RA patients in comparison with general population, we recommend the routine measurement of thyroid stimulating hormone to detect TD at an earlier stage, leading to earlier treatment initiation and improve prognosis. References Gabriel SE, Michaud K. Epidemiological studies in incidence, prevalence, mortality, and comorbidity of the rheumatic diseases. Arthritis Research & Therapy. 2009;11:229. Dougados M, Soubrier M, Antunez A, et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA). Ann Rheum Dis. 2014;73:62–8. Pan XF, Gu JQ, Shan ZY. Increased risk of thyroid autoimmunity in rheumatoid arthritis: a systematic review and meta-analysis. Endocrine. 2015;50:79–86. Acknowledgement We thank Danbio https://danbio-online.dk/. Disclosure of Interest None declared

Background Compliance to osteoporosis prophylaxis in postmenopausal women is described to be very poor [1]. The compliance to prophylactic osteoporosis medication in patients with inflammatory diseases treated with Glucocorticoids (GC) is higher [2], probably due to the risk of osteoporotic fractures as a side effect of GC treatment [3]. Objectives To evaluate the adherence to osteoporosis prophylaxis in a group of patients suffering from polymyalgia rheumatica (PMR) treated with GC. Methods At our department patients with milder disease are seen at every second consultations by a nurse specialized in rheumatology. At all nurse consultations the patients are asked, in a friendly and understanding manner, if they remember to take the prescribed calcium and vitamin D, as well as the name of the medication and where they buy it. If Bisphosphonate is prescribed they will be questioned about this as well. The nurses also check the date of dual-energy x-ray absorptiometry (DEXA) scans. In this cross sectional study, all patients (138) diagnosed with PMR within 2013 were interviewed about their compliance toward osteoporosis prophylaxis using a standardized questionnaire. Results 138 patients were identified, 20 patients were excluded (diagnoses were changes (12), did not want to participate (2), unreachable (3), found dementia (3)). A total of 118 patients were included. Of these 117 were prescribed calcium and vitamin D. 88.9% of these took the medication as prescribed. The reasons for the non-compliance were given as: “Forgetfulness, did not want to eat so many pills and side-effects”. Bisphosphonate was prescribed in patients (61) when the results of DEXA scan gave a T-score of less than -1. Of these patients 96.6% took the medication on a regular basis. Noncompliance to Bisphosphonate was in all cases due to gastrointestinal side effects. Conclusions Our results illustrate that it is possible to increase compliance considerably if the nurses at every consultation ask about the prophylactic medications, at least in this group of patients with a very painful disease. Furthermore we think that the friendly atmosphere, in which questions are given and the dialogue about the importance of the medication to avoid side effects of GC such as fractures, is very important. Our results should be confirmed in a randomized clinical trial, to rule out information bias. References Castelo-Branco C, Cortes X, Ferrer M; UNICAD study investigators. Treatment persistence and compliance with a combination of calcium and vitamin D. Climacteric. 2010;13:578–84. Emamifar A, Gildberg-Mortensen R, Andreas Just S, Lomborg N, Asmussen Andreasen R, Jensen Hansen IM. Level of Adherence to Prophylactic Osteoporosis Medication amongst Patients with Polymyalgia Rheumatica and Giant Cell Arteritis: A Cross-Sectional Study. Int J Rheumatol. 2015;2015:783709. Duru N, van der Goes MC, Jacobs JW, et al. EULAR evidence-based and consensus-based recommendations on the management of medium to high-dose glucocorticoid therapy in rheumatic diseases. Ann Rheum Dis. 2013;72:1905–13. Disclosure of Interest None declared

Background The increased exposure to heparin products for thromboprophylaxis against VTE in hospitalized patients raises concerns for an increase in the incidence of heparin-induced thrombocytopenia (HIT). Methods We analyzed, among 90,875 patients exposed to heparin products between 2005 and 2009, the number of hematologic consultations for thrombocytopenia, requests for heparin-induced antibodies by enzyme-linked immunosorbent assay, and cases given a diagnosis of HIT by the hematology consult service. Results We observed that despite a doubling in the number of patients receiving pharmacoprophylaxis with heparin, there was no significant increase in the number of consultations for thrombocytopenia, the number of requests for HIT tests, the number of positive HIT test results, or the number of HIT diagnoses. The number of cases of HIT was low and represented Conclusions We conclude that concerns about HIT should not be a limiting factor for the systematic implementation of heparin-based VTE prophylaxis.

Objectives: Adherence to the osteoporosis prophylaxis medications can play a significant role to prevent steroid-induced osteoporosis. The objective of this study was to evaluate the level of adherence to osteoporosis prophylaxis medications in newly diagnosed steroid-treated polymyalgia rheumatica (PMR)/giant cell arteritis (GCA) patients. Method: This is an ongoing prospective study. 37 consecutive pts. with newly diagnosed PMR/GCA were included in the study. The patients were requested to perform a total body DXA at time of diagnosis or shortly after. Hereafter, patients were contacted by nurses after a week of treatment initiation to evaluate the effect of treatment and to review the details. After 4 weeks of treatment with prednisolone, all included patients were interviewed about their compliance towards osteoporosis prophylaxis using a standardized questionnaire at first follow up visit. Patients were asked if they had remembered to take their prescribed medications. The standard treatment for prevention of osteoporosis was calcium (1200 mg/d) plus vitamin D (800 U/d) and 70 mg alendronate weekly (if T-score ≤−1). Results: Of 37 pts., 3 pts. were excluded from the study because of lack of interest or a change in the initial diagnosis. Statistical analyses were performed for the rest 34 pts. Results of DXA scan were available for 30 pts. Of all included pts. 61.8% were female and mean age (confidence interval) was 71 (69-74) y. 24 pts. had pure PMR symptoms, 2 pts. pure cranial GCA, 8 pts. with concurrent PMR and GCA. The cumulative prednisolone dose was 696.2 (516.9-1123.1) (median (interquartile range)). The mean of erythrocyte sedimentation rate 61.8 and C-reactive protein 44.9 at diagnosis decreased to 10.7 and 4.0, respectively, after 4 weeks of treatment. At time of diagnosis, 30% and 53.3% of pts. had osteoporosis (T-score ≤ -2.5) and osteopenia (-1≤ T-score