A. Fazaa

AB0254 The impact of the patient global assessment variation on the das 28 value

Background Rheumatoid arthritis (RA) is the most frequent chronic inflammatory rheumatism. The DAS 28 is a disease activity measure method used to assess RA activity. It is a composite score taking into account 4 items: the number of swollen joints/28, the number of tender joints/28, the erythrocyte sedimentation rate (ESR) or C reactive protein (CRP) rate, the patient global assessment (PGA) indicated on a 0–10 cm visual analogue scale (VAS) with ‘not active at all’ and ‘extremely active’ as anchors. The DAS28 determination is very important since it guides the therapeutic decision. Objectives The aim of this study was to determine the different ways of asking about the PGA and to assess the impact of its value variation on the calculation of the DAS 28. Methods In order to determine how to evaluate the GPA, a questionnaire including 4 propositions was asked to a cohort of Tunisian rheumatologists: how do you assess your health status this past week? what is the degree of the disease impact in your life this last week? what is the degree of the disease activity this last week? other Then, a DAS 28 calculation was proceeded according to the different choices of GPA question method for 10 Tunisian patients. Results The questionnaire was proposed to 37 rheumatologists, 15 working in the private sector and 22 in the public sector. These latter were 9 assistants, 3 professors, 5 specialist doctors and 5 associate professors. The first, second, third and fourth propositions were respectively chosen by 2, 14, 19 and 2 physicians. Subsequently DAS 28 was calculated. In the table 1 below, the variation of the DAS 28 value according to the choice of the PGA method is shown:Abstract AB0254 – Table 1 Patient DAS 28(PGA1) DAS 28(PGA2) DAS 28(PGA3) DeltaDAS 28(DAS28 max-min) 1 2.95 2.95 2.81 0.14 2 2.53 2.67 2.67 0.14 3 2.1 1.96 1.96 0.14 4 5.82 5.82 5.54 0.28 5 5.30 5.30 5.16 0.14 6 2.87 2.87 2.87 0.00 7 8.22 8.22 8.22 0.00 8 4.97 5.11 5.11 0.14 9 7.49 7.35 7.63 0.14 10 2.03 2.17 1.89 0.28 Conclusions The GPA question is a subjective item taken into account for the calculation of the DAS 28. Despite the different ways of asking about it, our study showed that this factor have no real impact on the DAS28 value variation since it doesn’t exceed 0.6. DAS28 remains a reliable tool in the clinical practice. Disclosure of Interest None declared

AB0285 Which Score is Better to Assess Remission in Rheumatoid Arthritis?: Table 1.

Background Various composite outcome measures have been developed in the last decade to evaluate Rheumatoid Arthritis (RA) activity, and the focus was in how to assess remission. The Ultrasonography (US) appears to be the best way to define remission but it is not always available. Objectives Our aim from this study was to investigate the accuracy of composite scores in classifying RA patients who were in remission using the absence of inflammatory activity detected by ultrasound (US) as a gold standard. Methods Sixty two patients followed up for RA were prospectively recruited. Among them, we identified patients in remission according to the Disease Activity Index 28 joints ≤2,6 (DAS28), the Simplified Disease Index ≤3,3 (SDAI), the Clinical Disease Index ≤2,8 (CDAI) and the American College of Rheumatology/European League Against Rheumatology (ACR/EULAR) 2011 criteria. B-mode and a Power Doppler (PD) US exam were assessed by a single rheumatologist who was experienced in US and blinded to the clinical and laboratory data. Twenty two joints were scanned (wrists, 10 metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints). Sensitivity, specificity and Positive Predictive value (PPV) for each score were calculated with as reference absence of Doppler signals in US. Results Among 62 patients screened, 30 (48%) were in remission according to the DAS28, 19 (31%) according to SDAI, 26 (42%) according to CDAI and 14 (23%) when new ACR/EULAR criteria were accomplished. Between all patients with active or not RA, nineteen had no Doppler signals in US. Considering “remission” to be the absence of joints with PD signal, the DAS28 was the most sensitive score while the ACR/EULAR criteria were the most specific. We resumed in table 1 our outcomes of sensitivity, specificity and PPV for each score of remission. Table 1. Sensitivity, specificity and PPV for different score of remission DAS28 SDAI CDAI ACR/EULAR Sensitivity 81,3% 56,3% 68,8% 31,3% Specificity 63,1% 78,3% 67,4% 80% PPV 43,3% 47,4% 42,3% 35,7% Conclusions Ours results suggest that when considering remission as an absence of Doppler signal, the sensitivity of DAS28 was better than SDAI, CDAI and ACR/EULAR definitions of remission. While the ACR/EULAR criteria were the most specific. References Balsa A, De Miguel E and col. Superiority of SDAI over DAS-28 in assessing remission in rheumatoid arthritis patients using power Doppler ultrasonography as a gold standard. Rheumatology 2010. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2958

AB0237 Joints count in rheumatoid arthritis: a correlation study between 3 clinicians and ultrasound joints count and the impact on disease activity

Background Tender and swollen joints count (TJC and SJC) are necessary to calculate the disease activity score DAS28 and to appreciate rheumatoid arthritis (RA) activity. Their accounting is very subjective and may differ between clinicians especially in wrist and hands joints. Ultrasound is excellent in detecting swollen joints. Objectives To evaluate correlation of TJC and SJC in wrists and hands between three rheumatologists with different practicing years experience. To evaluate correlation between SJC of each rheumatologist and sonography count. To assess their impact on DAS28 and the correlation between the DAS28 of each rheumatologist and ultrasound-DAS28. Methods We included 35 patients fulfilling the 1987 ARA criteria for RA. Each patient was examined (in double blinded) by 3 rheumatologists differing by their years of experience (Rheumatologist1=3 years, Rheumatologist2=7 years and Rheumatologist3=15 years). Within 2 hours of the clinical exam, sonography of the wrists, metacarpo-phalangeal, and proximal interphalangeal joints was performed. Synovial hypertrophy and/or joint effusion (SH/E) and power Doppler signal were identified in each joint for presence or absence. The approval of wrists and hands TJC and SJC between the three clinicians, then of the SJC between clinicians and ultrasound was assessed by calculating the correlation coefficient (CC). DAS28 of each clinician and ultrasound-DAS28 was calculated and the correlation was determined using the CC. Results There were 29 women and 7 men. Age ranged from 34 to 71 years with a mean age of 53,5 years. The mean disease duration was 8,6 years. Patients were receiving Methotrexate (77,1%), leflunomide (11,4%), rituximab (8,5 %), Sulfasalazine (5,7%). 74,2% of patients was receiving 6,5 mg/day mean dose of prednisone. The TJC in wrists and hands joints was highly correlated between the three physicians. The CC was between 0,794 and 0,889. Wrists and hands SJC evaluation was correlated between the 3 Rheumatologits, this correlation was moderate (CC=0,503-0,681). Only Rheumatologist2 and Rheumatologist3 wrists and hands SJC was correlated with sonography count, the CC was low (0,481 and 0,491). The higher CC with ultrasound was seen with Rheumatologist 3 (who has more years experiences). The correlations between the DAS-28 of each rheumatologist and the ultrasound-DAS28 was excellent (CC was respectively 0,946, 0,948 and 0,951). Conclusions Correlation between rheumatologists was good in wrists and hands TJC determination and moderate in SJC. In contrast, the correlation of Rheumatologists SJC and ultrasound was low and depending on clinician experience. However, due to the importance of the other items in the calculation of the DAS28, DAS28 correlation between the 3 clinicians and between DAS28-ultrasound was excellent. Disclosure of Interest None Declared

AB0023 Peripheral th17 cells in rheumatoid arthritis: correlation with the activity parameters of rheumatoid arthritis

Background Rheumatoid arthritis (RA) is a chronic inflammatory and autoimmune disease regulated by T lymphocyte subsets. Th17 lymphocytes reportedly play significant roles in the development of this disease. Objectives We investigated the correlation of circulating Th17 cells with the clinical and biological activity parameters in patients with RA. Methods This is a prospective study including patients with RA (1987 ACR criteria). Disease activity was evaluated by global pain intensity visual analog scale (VASP), visual analog scale for patient’s overall assessment of disease activity (VASOA), duration of morning stiffness, tender joint counts (TJCs), swollen joint counts (SJCs), erythrocyte sedimentation rate (ESR), C-Reactive Protein (CRP) and Disease Activity Score (DAS28). Peripheral blood Th17 cell frequency (LTh CD4+ IL-17+ IFNγ-) was determined with flow cytometry. Clinical examination and blood samples were performed on the same day. The significance level for Pearson correlation was set at p <0.05. Results Thirty-eight patients were included, 35 women and 3 men, with a mean age of 52.4 ± 10.3 years and a mean disease duration of 124 ± 98 months (7-456 months). The mean VASP arose to 57 mm [0-100], the mean VASOA to 58 mm [0-100] and the mean duration of morning stiffness to 37.76 minutes [0-240]. The mean TJCs and SJCs were 7 and 6, respectively. A biological inflammatory syndrome was noted in 33 patients with a mean ESR of 46 ± VS 25 mm [15-110] and a mean CRP of 16.8 ± 15 mg / l [5-59]. The mean DAS28 was 5.2. Distribution according to the activity level of the disease showed a high activity for 20 patients according to the DAS28. There was no significant correlation between the percentage of peripheral LTh17 and the various parameters of clinical and biological activity studied. Conclusions Even though Th17 cells involvement in the pathogenesis of RA is now well established, our study shows that the peripheral percentage of Th17 cells is not correlated with the disease activity. Their frequency in rheumatoid synovial fluid might show a better activity index. References Gullick NJ, Evans HG, Church LD, Jayaraj DM, Filer A, et al. (2010) Linking Power Doppler Ultrasound to the Presence of Th17 Cells in the Rheumatoid Arthritis Joint. PLoS ONE 5(9): e12516. doi:10.1371/journal.pone.0012516 Disclosure of Interest None Declared

AB0044 Correlation of peripheral il17 cytokine with activity parameters and ultrasound scores in rheumatoid arthritis

Background It is now recognized that some pro-inflammatory cytokines, such as IL-17, contribute to synovial neoangiogenesis and osteocartilaginous destruction in rheumatoid arthritis (RA). The serum concentration of this cytokine has also been associated with the disease activity. Objectives The present study sought to determine the relationship between IL-17 plasma concentration and clinical, biological and ultrasound activity parameters in patients with RA. Methods This is a prospective study including patients with RA (1987 ACR criteria). Disease activity was evaluated by global pain intensity visual analog scale (VASP), visual analog scale for patient’s overall assessment of disease activity (VASOA), duration of morning stiffness, tender joint counts (TJCs), swollen joint counts (SJCs), erythrocyte sedimentation rate (ESR), C-Reactive Protein (CRP) and Disease Activity Score (DAS28). The patients underwent blinded power Doppler ultrasonography (PDUS) and grey-scale ultrasonography (GSUS) examination of 22 joints (10 metacarpophalangeal, 10 proximal interphalangeal and wrists), within the 2 hours of clinical assessment, using a handheld 13-18 MHz transducer. In GSUS, the grade ranged from 0 (no synovial thickening, no articular effusion) to 3 (marked synovial thickening). Similarly, in PDUS, the grade ranged from 0 (absence of signal) to 3 (confluent vessel signals in more than 50% of the synovial area). PDUS and GSUS semi-quantitative scores were established, ranging from 0 to 66 and corresponding to the sum of the different grades for each joint. The plasma concentration of IL-17 was determined by enzyme-linked immunosorbent assay (ELISA) kits. The significance level for Pearson correlation was set at p <0.05. Results A total of 38 patients with RA were evaluated, 5 were male. Their ages ranged from 30 to 70 years (mean: 52.4 ± 10.3 years). Their histories of RA ranged from 7 to 456 months (mean: 124 ± 98 months). The mean VASP arose to 57 mm [0-100], the mean VASOA to 58 mm [0-100] and the mean duration of morning stiffness to 37.76 minutes [0-240]. The mean TJCs, SJCs, ESR, CRP and DAS28 were 7, 6, 46, 16.8 and 5.2, respectively. The score average value in GSUS was 17 ± 14 [0-51] and that in the PDUS 14 ± 14 [0-53]. The mean plasma concentration of IL-17 was 7.8 IU [5.81-22.49]. The CRP value was significantly and positively correlated with the plasma concentration of IL-17 (p=0.025, r=0.374). The GSUS and PDUS score was significantly and strongly correlated with the concentration of IL 17 (p=0.007 and p=0.000). Conclusions Our study shows that the plasma concentration of IL-17 may serve as a quantitative index of the disease activity in RA. References Leipe J, Grunke M, Dechant C, Reindl C, Kerzendorf U, Schulze-Koops H, Skapenko A. Role of Th17 Cells in Human Autoimmune Arthritis. Arthritis Rheum 2010;62:2876–85. Disclosure of Interest None Declared

AB0671 Comparison between the effect of acupuncture and conventional medical treatment in acute torticollis

Background Acute torticollis is a common disease, causing severe discomfort and temporary inability to work. Medical treatment is not without side-effects. Acupuncture could be an interesting alternative. Objectives Evaluate the immediate effect of acupuncture in the treatment of acute torticollis and compare this response to that obtained by medical treatment. Methods It is a controlled randomized therapeutic test, carried out at the acupuncture department of the Internal Security Forces Hospital. Patients who consulted between October 2011 and March 2012 for a first fit of acute torticollis evolving for less than 48 hours were randomized into 2 groups of 20 patients each. Patients with symptomatic torticollis were excluded. Group 1 (G1) received acupuncture treatment alone. One to three sessions of needle acupuncture were performed according to the rules of traditional Chinese medicine. We used a single distal point, Houxi (IG.3). Group 2 (G2) was treated with analgesic, anti-inflammatory and muscle relaxing for 7 days. The assessment focused on the pain through visual analogical scale (VAS) and on the mobility of the cervical spine (Chin-sternum distance, chin-acromion distance, earlobe–acromion distance) at baseline, at the end of each acupuncture session for G1, the 7th day of medical treatment for G2 and 15 days after the end of treatment for both groups. Results The patients’ average age was 34 years (12-57) with a female predominance (sex ratio 0.8). The character of the pain, according to the 8 rules of traditional Chinese medicine, was fullness type in 55% of cases, external type in 25% of cases and internal type as emotional response in 20% of cases. For each group, the decrease in mean VAS between the beginning and the end of treatment was statistically significant. Eighty percent of the patients in G1 were cured after one session of acupuncture. The comparison between the two groups showed a decrease in mean VAS greater for G1 with a statistically significant difference (p <0.05). Improvement in measurements was significant in the two groups except for the earlobe–acromion distance for G2. The result was better for G1 but without significant difference. No patient in G1 had to stop working while in G2 the sick leave averaged 2.4 days. No recurrence was observed 15 days after the end of treatment for either group. No adverse reactions were observed for G1. Digestive disorders were noticed in 10% in G2. Conclusions Our results show that needle acupuncture is an effective and safe short term treatment for people with acute torticollis. It has beneficial effects on mobility and pain related to motion in those patients. It seems more effective than pharmacotherapy alone. References Shigang H. Clinical observations on the treatment of 50 cases of stiff neck by acupuncture. J Trad Chin Med 1992;12:57-8. Disclosure of Interest None Declared