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Background Ultrasound (US) has shown to be a sensitive imaging tool for the detection of subclinical signs of synovitis in patients (pts) with rheumatoid arthritis (RA); further studies are still required to delineate the impact of US findings in the management of RA pts in daily clinical practice. Objectives To investigate the relationship between US findings indicative of joint inflammation and US bone erosions at joint level in pts with RA. Methods In 2015 an educational event focused on the added value of US in RA pts was held in 22 rheumatology centers in Italy. In every center, the local rheumatologists provided RA pts to be examined by US. Pts signed an informed consent and a brief history of them was collected by the local rheumatologists (previous and current therapy, DAS28, HAQ score). Bilateral US examinations of wrists, metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints were performed by rheumatologists expert in US, to assess synovitis (joint effusion, synovial proliferation, and power Doppler (PD) signal), and bone erosions, using a Logiq E R7, General Electrics, with a 4.2–13 MHz linear probe. All US findings were scored using a 4 degree semiquantitative scoring system. Results In 465 RA pts, a total of 10.230 joints were scanned. Of these joints, 3.969 (39%) showed joint effusion and/or synovial proliferation and 1.784 (17%) were found positive for PD signal. The most frequently involved joints were the wrists followed by the second MCP joints and first MTP joints. In 749 joints US detected at least one bone erosion. The most frequently eroded joints were the wrists, the second and fifth MCP joints and the first and fifth MTP joints. A total of 226 RA pts showed at least one bone erosions and in 181 (80%) of these pts the eroded joints were found positive for PD signal. Conclusions A high prevalence of PD signal was found in the joints found eroded by US. This is the first study providing such an evidence using a portable US equipment. Disclosure of Interest None declared

Background Ultrasound (US) examination is able to show subclinical synovitis and structural changes of joints in patients (pts) with RA in clinical remission (CR). Objectives To investigate the differencies of US examination of small joints of hands, feet and wrists in pts with very early (VERA, 7 y duration) in clinical remission (CR). Methods In 2015 an educational event (RECALL survey) focused on the added value of US in RA pts was held in 22 rheumatology centers in Italy. In every center, the local rheumatologists provided RA pts to be examined by US. Pts signed an informed consent and a brief history of them was collected by the local rheumatologists (previous and current therapy, DAS28, HAQ score). Bilateral US examinations of wrists, metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints were performed by rheumatologists expert in US, to assess synovitis (joint effusion, synovial proliferation, and power Doppler (PD) signal), and bone erosions, using a Logiq E R7, General Electrics, with a 4.2–13 MHz linear probe. All US findings were scored using a 4 degree semiquantitative scoring system. Results Eighty-eight pts were classified as VERA, 183 as ERA and 165 as LRA. Drug usage was not different among the three groups of pts. LRA patients were older (p Conclusions At US examination VERA, ERA and LRA pts in CR have the same degree of synovial hyperplasia and PD signal despite the differences of duration of CR. Higher degree of erosive disease (at wrist and MTP joints), lower degree of MTP effusion and higher prevalence of joint effusion at MTP joints were present among LRA vs ERA and VERA pts. Disclosure of Interest None declared

Background In Rheumatoid Arthritis (RA) treatment response is assessed using standard clinical disease activity measure. However ultrasound (US) is able to show subclinical synovitis in patients (pts) with RA who are in clinical remission (CR); further studies are still required to delineate the impact of US findings in the management of RA pts in daily clinical practice. Objectives to investigate the influence of US on the clinicians9 treatment choices in pts with RA. Methods in 2015 an educational event (RECALL Survey) focused on the added value of US in RA pts was held in 22 rheumatology centers in Italy.In every center, the local rheumatologists provided RA pts to be examined by US. Pts signed an informed consent and a brief history of them was collected by the local rheumatologists (previous and current therapy, DAS28, HAQ score). Bilateral US examinations of wrists, metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints were performed by rheumatologists expert in US, to assess synovitis (joint effusion, synovial proliferation, and power Doppler (PD) signal), and bone erosions, using a Logiq E R7, General Electrics, with a 4.2–13 MHz linear probe. All US findings were scored using a 4 degree semiquantitative scoring system. Results 465 pts were evaluated. Clinicians, after US evaluations, changed therapy in 23.7% of pts, did not change therapy in 35.5% of pts.In general changes of therapy tended to be made by clinicians when joint effusion or power Doppler signal were present (table 1–2). The presence of erosion did not influence the clinicians9 decisions. Conclusions Ultrasound may be an useful tool in daily rheumatologic practice to help clinicians make decisions about how to treat patients with RA. US results, especially joint effusion and Power Doppler signal, may influence the choice of clinicians to modify a patient9s treatment regime. Disclosure of Interest None declared

The aim of the study was to review from the present literature the intra-articular (IA) use of the TNF-blocking drugs. A total of 28 papers about this topic were found through a search in PubMed; the first publication's date was July 2003. These studies include a total of 214 patients affected by 12 different joint diseases that reported a total of 1046 intra-articular therapies carried out in 10 different joint sites. Infliximab and etanercept were the most widely used medications. The safety of this treatment clearly emerges from our analysis, while more difficult was the evaluation of its efficacy. Nevertheless we deduced an ideal patient profile that may better respond to the IA anti-TNF treatment.

The so-called papular-purpuric gloves and socks syndrome (PPGSS) is a condition characterized by acute onset of intense erythema, edema and petechiae with a typical localization on the hands and feet, besides mucosal lesions of the oral cavity. The syndrome has a favorable and self-limited course, requiring only a symptomatic therapy. In the 50% of the cases described in literature (ninety cases in 22 years), is documented an acute infection caused by parvovirus B19 and in only two cases the onset of PPGSS is reported among different members of the same family. The aim of the work is to describe two cases of PPGSS arisen during a short time period in two family members affected by an acute parvovirus B19 infection found by serum sampling. The peculiarity of the study was the infrequence of the syndrome and the rareness of the description of PPGSS in rheumatology. This syndrome is usually described in dermatology, but it is also interesting for the rheumatologist because it comes in differential diagnosis with various autoimmune diseases.

Erasmus syndrome is defined as the association of silica exposure and subsequent development of systemic sclerosis. The limited number of cases reported in the literature mainly involves miners and only sporadically other professionals. We describe a case of Erasmus syndrome in a marble worker. A 68 year old man came to our observation complaining pelvic and scapular girdle pain, evening fever, intense weakness and emaciation for about 1 month. He also reported to have had Raynaud’s phenomenon in his hands for the last 13 years. Also, his occupational history revealed a chronic exposure to silica dust. The patient presented pain in his shoulders and hips, moderate skin thickening and sclerosis in his hands and fingers extending proximally to his wrists. The diagnosis of systemic sclerosis was determined according to his clinical and medical history, the positivity of anti-Scl 70 antibodies, the nailfold capillaroscopy suggestive of an active scleroderma pattern and the detection of a mild restrictive pulmonary syndrome. The evaluation of the organbased complications excluded a gastroenterological and cardiovascular involvement, while the chest computed tomography (CT) detected multiple small nodules with a mantle distribution and enlarged lymph nodes with no signs of interstitial lung disease and fibrosis. Additional tests (positron emission tomography-CT, flexible bronchoscopy and broncho-alveolar lavage) excluded infectious diseases and cancer. However, given the pulmonary involvement, we performed a histological examination of the parenchyma and lymph nodes, which revealed a picture of pneumoconiosis. In the end, the occupational history and the findings from the diagnostic procedures led to the diagnosis of pulmonary silicosis. The precise definition of the pulmonary involvement was essential to the therapeutic approach to this patient.

Background: Osteoporosis is a highly prevalent disease and fractures are a major cause of disability and morbidity. Aim: The purpose of this study was to characterize post-menopausal women attending osteoporosis centers in Italy, to evaluate physician management, and to determine the incidence of first osteoporotic fracture. Subjects and methods: PROTEO-1 was an observational longitudinal study with a 12-month follow-up. Data were collected from women attending osteoporosis centers. Women without prevalent fracture were eligible to enter the 1-yr follow-up phase: the clinical approach to patients according to their fracture risk profile and the incidence of fracture were recorded. Results: 4269 patients were enrolled in 80 centers in the cross-sectional phase; 34.2% had an osteoporotic fracture at baseline. Patients with prevalent fractures were older and more likely to be treated compared with non-fractured patients. The incidence of vertebral or hip fracture after 1 yr was 3.84%, regardless of the calculated risk factor profile, and was significantly higher in patients with back pain at baseline (4.2%) compared with those without back pain (2.2%; p=0.023). Generally, physicians prescribed more blood exams and drugs to patients at higher risk of fracture. Among fractured patients only 24% were properly treated; the rate of non-responders to treatment was about 4%. Conclusions: In a large, unselected sample of post-menopausal women attending osteoporosis centers, those without previous fracture were at substantial risk of future fracture, regardless of their theoretical low 10-yr fracture risk. The presence of back pain in women without previous fracture warrants close attention.

Objectives The aim of this study was to evaluate into a cohort of patients assessed for sicca syndrome the prevalence of secondary Syogren9s syndrome (sSS) in patients affected by spondyloarthritis (SpA), considering SpA a possible cause of sSS. Methods We evaluated,from December 2009 to December 2014 a total of 221 consecutive patients affected by sicca syndrome for suspected Sjogren9s syndrome (SS), 208 females and 13 males aged between 23 and 89 years(mean age 50.94 years). Each patient underwent minor salivary glands biopsy, anti-nuclear antibodies detection, anti-Ro and anti-La antibodies detection, Schirmer test, salivary gland scintigraphy and anti-HCV serology. The acute phase reactants,the C3 and C4 complement fractions were also simultaneously evaluated and ultrasonography of both the parotid and submandibular glands was performed and assessed with the grading proposed by Salaffi et al. (range 0-4). The classification of the patients affected by primary SS (pSS) and sSS was made according to the American-European Consensus Group criteria considering SpA, arbitrarily, among the other diseases cause of sSS. The classification of the patients with SpA was made only on patients that meet the modified New York criteria or the CASPAR criteria or the Amor criteria or the ESSG criteria or the ASAS criteria for the axial or the peripheral spondyloarthritis. The statistical analysis was carried out using the Kolmogorov-Smirnov test to check the distribution, the Student9s t-test for the comparison between the groups and the χ 2 -test to compare the categorical variables and the proportions; a p value Results 141 patients were classified as affected by SS and in particular 84 with pSS and 57 with sSS; the data were inadequate in 80 patients for the definition of SS (46 patients with essential sicca syndrome and 34 with UCTD). 21 of the 57 patients with sSS were affected by spondyloarthritis (36.84%) and the SS resulted secondary to rheumatoid arthritis in 20 patients (RA; 35.08%). The two groups of patients, one with sSS and SpA and the other one with sSS and RA were not reporting substantial differences in the average age, sex and in the Schirmer test positivity (51,76±12,5 vs 47,60±15,9 years, p=0.35; 20/21 vs 18/20 females, p=0.5; 90.47 vs 90.00%, p=0.66); the anti-nuclear antibodies, the anti-Ro/anti-La antibodies, the anti-CCP antibodies and the rheumatoid factor detection (61.90 vs 90.00%, p>0.05; 14.28 vs 50.00%, p=0.016; 19.04 vs 75.00%, p=0.001; 9.52 vs 80.00%, p Conclusions Since SpA were considered a possible cause of sSS,these patients represent in our series 9.50% of all the patients assessed for sicca syndrome, 14.89% of the patients with SS and 36.84% of the patients with sSS.Comparing sSS-SpA patients and sSS-RA patients the only statistically significant differences resulted in the lower frequency of anti-Ro/anti-La antibodies, anti-CCP antibodies and rheumatoid factor positive detection in patients with SpA.The data reported suggest the evaluation of the sicca symptoms in patients with spondyloarthritis in agreement with other studies in the literature. Disclosure of Interest None declared

Objectives The persistence in therapy is an important assessment tool of therapy efficacy in patient with chronic disease. The aim of this study was to evaluate drug survival (DS) of a patients cohort suffering from chronic inflammatory rheumatism treated with abatacept. Methods From September 2008 to March 2013, we retrospectively observed a total of 107 patients starting therapy with abatacept, in a single center of southern Italy. They were 88 females and 19 males, aged between 21 and 85 years (54.65) and with disease duration between 2 and 45 years (11,71). 60 patients were suffering from rheumatoid arthritis (RA; 56.07%), 6 from chronic undifferentiated polyarthritis (5.60%), 2 from juvenile idiopathic arthritis (1.86%), 1 from Still9s disease (0,93%) and 38 (35.51%) from seronegative spondyloarthritis (SpA). 91.58% (98 patients) had also comorbidities. 18.69% of the patients (20 patients) were naive to the treatment with biological drugs. 77.00% of patients took DMARDs and 69,39% were receiving steroid. Results DS resulted averaging 15.40 months, retention rate after 1 year (RR1) was 49.53% and after 2 years (RR2) was 25.23%. Half of the patients (53 patients, 49.53%) interrupted the therapy during the observation period, mostly due to inefficacy or loss of efficacy (64.15%) and only 3.77% due to side effects. DS, RR1 and RR2 were clearly higher in patients taking DMARDs compared to patients taking abatacept in monotherapy (14.58 vs 11.26 months, p= ns; 50.64% vs 30.43%, p=0.038 and 24.67% vs 8.69%, p=0.042, respectively). The RA patients showed higher values of the examined parameters compared to the patients with SpA (DS: 17.31 vs 11.36 months, p=0.029; RR1: 53.33% vs 44.73%, p= ns; RR2: 33.33% vs 7.89%, p=0.0001). Considering patients in first-line vs patients in subsequent lines of biological therapy DS resulted 12.50 vs 16.06 months, RR1 45.60% vs 50.57% and RR2 20.00% vs 26.43%; this result could be justified by the shorter period of observation of patients in first-line of biological therapy, due to the more recent use of abatacept in patients naive to biological therapy. 80.00% of these patients resulted in fact still in therapy at the end of the observation vs 43.67% of the patients in subsequent lines of biological therapy (p=0.0001).The average value of DAS 28 and good or moderate EULAR response achievement appeared better in patients in first line of biological treatment (3.59 vs 4.04, p=ns and 63.16% vs. 46.57%, p=0.0228, respectively). Conclusions Into a cohort of patients with chronic inflammatory rheumatism and treated with abatacept DS was in line with the results reported in few studies on the subject. The persistence in therapy was better in patients with RA compared to patients with SpA and in patients treated with DMARDs compared with patients taking abatacept in monotherapy. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2669

Objectives TNFα is a key cytokine in the integrated host defence system against infectious diseases, acting on both the innate and the adaptive immune system. Anti-TNF agents may elicit Hepatitis B Virus (HBV) reactivation in patients with positive serology for HBV markers. Few data regarding the safety of these agents in the setting of chronic viral infections are available, and these are mainly based on case reports. According to our knowledge this is the first retrospective analysis on safety of certolizumab pegol in patients with previous HBV exposure. Methods Among 35 patients with rheumatoid arthritis treated with certolizumab pegol in a single center of the southern Italy, we identified 10 patients with previous documented HBV exposure, 2 male and 8 female with average age 55,5 years old; 8/10 resulted RF+, 4/10 RF+ and anti-CCP+. 8 were treated with DMARDs (6 methotrexate 10-15 mg/week, 1 cyclosporine A 150 mg/day, 1 idroxyclorochine 200 mg/day+ salazopyrin 1000mg/day) and 1 with mesalazine 800 mg/day. 9/10 were treated also with corticosteroids at low dosage (prednisone 2,5-12,5 mg/day, mean 5.5). 9 patients were HBsAg- and HBV serology was respective anti-HBs+ (8/9), HBeAg- (9/9), anti-HBe- (6/9), anti-HBc IgM- (9/9), anti-HBc IgG+ (6/9). 1 patient resulted HBsAg+, anti-HBs-, HBeAg-, anti-HBe+, anti-HBc IgM- and anti-HBc IgG+, and was on treatment with entecavir 0,5 mg/day since 3 years. Disease activity, inflammatory markers, transaminase levels, HBV markers and HBV-DNA where periodically monitored according to the local standard of care. Results Patients were monitored from 3 to 22 months (overall 110 months, mean 11 months). On this period none of the patients showed variation in HBV markers with stable anti-HBs titre (mean 761 vs 697mlU/ml); only 1 patient showed an increase in GPT ( Conclusions Into a cohortof patients with rheumatoid arthritis and treated with certolizumab pegol, 28.5% showed a previous contact with HBV. Therapy with certolizumab pegol showed to be safe although performed in combination with DMARDs and steroids and in the observation period HBV reactivation was not recorded in any patient. In one HBV inactive carrier patient the association therapy with certolizumab pegol and entecavir showed safety and efficacy for 12 months. Disclosure of Interest None Declared

Objectives This study aims to describe the sonographic abnormalities of the major salivary glands in patients evaluated for sicca syndrome. Methods 110 consecutive patients with sicca syndrome, 104 females and 6 males, aged between 23 and 81 years (mean age 50,9), were studied for suspected diagnosis of Sjogren’s Syndrome (SS). The classification of patients with SS was made according to the American-European Consensus Group criteria. Minor salivary gland biopsy was performed in accordance with the procedure proposed by Daniels et al and the histopathologic findings were evaluated through the Chisholm and Mason classification: the presence of at least 1 focus of mononuclear leukocytes in 4 mm 2 was considered positive (Daniels et al.). US of both the parotid and submandibular glands was assessed with the grading proposed by Salaffi et al.(range 0-4). Results 70 of the110 considered patients were classified as affected by SS (SS group: 4 males and 66 females, mean age 52,5, 41 with primary SS and 29 with secondary SS). In 40 patients the data were inadequate for the definition of SS (NSS group: 2 males and 38 females, mean age 48,2, 22 with undifferentiated connective tissue disease (UCTD) and 18 with essential sicca syndrome). Sonographic abnormalities (range 1-4) were found in 91,4% of the SS patients vs 75,0% in NSS group (p Conclusions The mayor salivary gland US in our experience, if considered by itself was shown to be a sensitive but nonspecific technique, very specific but less sensitive when considered in combination with histology or anti-Ro/anti-La antibodies positivity. The SS patients presented more often an advanced US grading than the NSS patients. Finally in the SS patients with positive histology or anti-Ro/anti-La antibodies positivity we frequently found a more advanced US grading. Disclosure of Interest None Declared

A study was carried out to verify the efficacy of intra-articular orgotein in patients with different forms of hydrarthrosis of the knee. The results confirm the value of orgotein for the local treatment of osteoarthritic joint swellings. However in the presence of marked exudative synovitis processes (chronic primary polyarthritis), the use of orgotein is of limited value.

This study aimed to evaluate the incidence of influenza-like illness (ILI), from October 2009 to May 2010, in a group of patients suffering from chronic inflammatory rheumatism and treated with biological therapies. At the end of 2009-2010 influenza season, 159 patients under biological therapies answered to a questionnaire distributed 8 months before and were deeply interviewed. The group included 69 men and 90 women (mean age 47.6); forty-nine suffering from rheumatoid arthritis, 61 with psoriatic arthritis, 32 with ankylosing spondylitis and 17 with other spondyloarthritis; 146 patients were treated with anti-TNF-α, 7 with rituximab and 6 with abatacept; 128 patients assumed DMARDs and 72 patients assumed low dose of steroids. A case of ILI was identified by anamnestic findings and according to the case definitions commonly used in Europe. Seventeen percent of the considered population reported at least one episode of ILI during the monitoring period; none of the patients during the acute influenza attack suffered particularly severe symptoms and no one was hospitalized due to complications. Despite the diversity among the considered subgroups, the statistical analysis did not show any significant difference when incidence of ILI was considered for different disease, different biological agent and different association therapy. None of the examined variables resulted statistically significant concerning the relative risk evaluation. The incidence of ILI into a cohort of 159 patients treated with biological agents during the influenza season 2009-2010 resulted higher than the value reported in a wide sample of Italian population in the same period. However, the pandemic impact was not heavy among the studied patients, considering that no important complications or hospitalizations have been reported.