A. Laatar

Role of ultrasound in assessing remission in rheumatoid arthritis

INTRODUCTION Remission is the ultimate goal of the treatment of rheumatoid arthritis (RA). However, the diagnosis of remission might still be vague. Musculoskeletal ultrasound (US) seems to effectively assess synovitis, effusion and bone damage. Thus, its role could be relevant for the diagnosis, monitoring or detection of relapse in the follow-up of RA in remission. The goal of this review of the literature was to clarify the added value of ultrasonography during remission. METHODS A systemic search of the literature was performed on Medline and Scopus. The following key words were used: rheumatoid arthritis, remission, US. Fifty-six papers were collected, then after an in depth analysis, twelve articles were selected for analysis. RESULTS Twelve papers were identified that assessed remission in RA. Remission criteria varied from one author to another. The number of joints assessed by US varied from six to 44 with the wrist and metacarpo-phalangeal joints of the dominant hand scanned at least. Irrespective of remission criteria, all authors demonstrated that US detected Doppler positive synovitis in patients in clinical remission. Also, power Doppler synovitis predicted structural damage and future flares of RA. CONCLUSION US seems to be more effective than a clinical exam. True remission in RA must be defined. Moreover, the inclusion of this technique in the new definition of remission is being validated.

Rheumatoid arthritis in the Middle East and Africa: are we any closer to optimising its management?

A recent editorial considered the management of rheumatoid arthritis (RA) in the Middle East and Africa [1]. Following review of the limited available evidence in the literature specifically that is from this region, it was suggested that management of RA is suboptimal for a variety of reasons [1]. The editorial authors met to determine whether the European League Against Rheumatism (EULAR) consensus recommendations published in 2010 [2] were applicable and appropriate for implementation in the MENA region and South Africa [1]. The group made recommendations on next steps to improve the management of RA in this region, including collection of epidemiological data to elucidate better the prevalence, severity and burden of RA in this region; educational initiatives to raise awareness of the disease and dispel misconceptions among health care professionals (HCPs) and patients; development of regional guidelines to increase implementation of an evidence-based approach and improve outcomes; and facilitation of access to treatments in line with the recommendations [1]. In addition, locally relevant issues not commonly seen in Europe such as high rates of hepatitis B and C, tuberculosis (TB) and parasitic infections as well as access and monitoring difficulties should be considered.

Chronic Inflammatory Rheumatism Associated With Takayasu Disease

Takayasu disease is rarely associated with other autoimmune diseases. Therefore, the cases discussued herein are uncommon because we are reporting Takayasu disease associated with rheumatoid polyarthritis and spondylarthropathy. The first case concerns a 40-year-old woman presenting with Takayasu disease 11 years after the diagnosis of erosive and seronegative rheumatoid polyarthritis. The upper limb arteries and 1 lower limb artery were affected. The second 41-year-old case presented with ankylosing spondylitis that had been evolving for 10 years. Human leukocyte antigen-B27 typing was negative. Takayasu disease was revealed by severe high blood pressure. In both cases, radiologic examination revealed a typical aspect of the aorta and its main collaterals. Rarely in the literature have these associations been reported, and the pathology remains unknown.

Reparative radiological changes of hip joint after TNF inhibitors in ankylosing spondylitis

Background: Hip involvement in ankylosing spondylitis (AS) is a common extraspinal arthritic manifestation, which is associated to a worse functional outcome. Little data are available on the effectiveness of conservative treatment strategies. The TNF inhibitors have been proven effective on AS activity parameters. Their structural effect on hip disease however, little is studied. Case presentation: We describe four new cases of reparative changes of a damaged hip joint after treatment with TNF inhibitors. The average of age was 32.5 (27- 36) years. There were 3 men and 1 woman. Hip involvement was bilateral in all cases. Etanercept was prescribed in 3 cases and infliximab in 1 case. At baseline, all patients had a painful and limited hip with high disease activity and an important functional impairment. After an average of 5.5 years of treatment with TNF inhibitors, the BASRI hip evaluated in antero-posterior x-rays of the pelvis remained unchanged at 2.4. The average of mean hip joint space was 2.9mm (2.3-3.6). A widening in hip joint space was observed in all cases with less subchondral cysts. Conclusion: TNF inhibitors seem to be effective on hip joint disease in patients with AS.

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

SAT0053 The Added Value of Ultrasound to Evaluate Remission in Rheumatoid Arthritis: Table 1.

Background Various definitions of remission in Rheumatoid Arthritis (RA) have been proposed. The Disease Activity Index 28 joints (DAS28) is the routinely used score. Newer tools for evaluation of RA activity include the Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI) are available and have proved to be more stringent. Objectives The purpose of this study was to compare the accuracy of composite scores of remission in RA patients using the absence of inflammatory activity detected by ultrasound (US) as a gold standard. Methods Sixty seven patients followed-up for RA were recruited. 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)). SDAI and CDAI were calculated for each patient. Sensitivity, specificity and Positive Predictive value (PPV) for each score was calculated with as reference absence of Doppler signal in US. Then ROC curve were analyzed. Results Among all patients, 30 were in remission according to the DAS28, 19 according to SDAI and 26 according to CDAI. For 19 patients there was no Doppler signal in US. The sensitivity and specificity of different remission scores considering as reference absence of joints with PD signal is showed in table 1. Table 1. Sensitivity, specificity for different remission criteria DAS28 SDAI CDAI Sensitivity 81,3% 56,3% 68,8% Specificity 63,1% 78,3% 67,4% The ROC curves showed that the best threshold of DAS28 was 3.2. It was 6.5 for SDAI and 8 for CDAI. Conclusions Ours results suggest that when considering remission as an absence of Doppler signal, the DAS28 was the most sensitive and the CDAI was the most specific. The ROC curves showed threshold exceeding definition of remission. 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

AB0955 Randomized Trial Comparing Acupuncture with and Without Bloodletting in the Treatment of Sciatica: A Study of 40 Cases

Background Sciatica is one of the most severe neuralgic diseases. Until today, there have been no ideal treatments for this affection. Current pharmacologic therapies are inadequate for many patients. Besides, some adverse effects may occur. To remain pain free, acupuncture is used as an interesting alternative for sciatica treatment. Objectives This study aims to compare the efficacy of acupuncture used as monotherapy to its efficacy when combined with bloodletting in the treatment of sciatica. Methods A prospective clinical trial was performed with patients suffering from sciatica who were randomly assigned to one of two groups: patients (20 cases) who were treated by acupuncture plus bloodletting (group 1) (G1) and patients (20 cases) who were treated by simple acupuncture (group 2) (G2). All patients received the treatment 3 times a week for 20 minutes for a total of 10 sessions. The visual analogical scale (VAS) pain score and the Lasègues sign (LS) were assessed at baseline, at the third, sixth, ninth and last visit. Results Forty cases of sciatica ranging in age from 31-70 years were treated in this study. 15 (37%) among them were females while 25 (63%) were males. The average time between the start of clinical symptoms and the first acupuncture session was 38.6 [2, 120] months. 90% of patients had sciatica pain lasting 6 months or more. 37 patients (92.5%) finished the protocol: 19 (95%) in G1 and 18 (90%) in G2. The mean VAS pain score in G1 was 7.15 at baseline. It was reduced to 0.75 after the tenth session. A significant decrease of mean VAS pain was also observed in G2 (from 6.8 at baseline to 1.15 after the tenth session). LS was negative in 4 cases (2%) in G1 versus 2 cases (1%) in G2 at baseline. After the tenth session, it became negative in 18 cases (90%) in G1 versus 17 cases in G2. A statistically significant difference (p<0.05) between different sessions was noted. Comparing the two groups, the decrease of mean VAS was more pronounced in G1. However, this difference was not statistically significant (p>0.05). Moreover, there was no significant difference between the two groups concerning the improvement of the LS. 94.7% of patients in G1 were satisfied at the end of the cure versus 88.8% of patients in G2. Conclusions These results suggest that acupuncture therapy is beneficial, effective and safe in the treatment of sciatica, especially when associated to bloodletting. Since this therapy avoids drugs side effects, it should be more considered. A large scale rigorously designed study is warranted to confirm the current results. Another challenge lies in how to clinically combine acupuncture, bloodletting and Western medicine. References Chen MR. The warming acupuncture for treatment of sciatica in 30 cases. J Tradit Chin Med 2009. M Hollisaz. Use of Elctroacupuncture for Treatment of Chronic sciatic Pain. The Internet Journal of Pain, Symptom Control and Palliative Care. 2006;5(1). 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

AB0988 Effect of Football on Knee Cartilage Thickness: an Ultrasonographic Assessment

Background The effect of physical activity on Knee joint especially the cartilage is unclear. Objectives The aim of the study was to assess the ultrasonographic thickness measurements of knee cartilage in asymptomatic soccer players (SP) compared to sedentary controls. Methods A prospective comparative study including 28 males divided into 2 groups: (1) asymptomatic SP recruited from sporting clubs and (2) control group that had never been physically active on a regular basis. Ultrasonography (Esaote MyLab 60 machine and a 13 MHz linear array transducer) was performed on knee joints by a rheumatologist with theoretical and practical training in musculoskeletal ultrasonography and blinded to the identity of subject. With subjects sitting in a comfortable position on the examination table with their knees in maximum flexion, the probe was placed in an axial position on the suprapatellar area. The distal femoral cartilage was visualized as a strongly anechoic structure between the sharp bony cortex and the suprapatellar fat. Three (mid-point) measurements were taken from each knee: the right lateral condyle (RLC), the right intercondylar area (RIA), the right medial condyle (RMC), the left medial condyle (LMC), the left intercondylar area (LIA), and the left lateral condyle (LLC). Both statistical and descriptive analyses were performed. Results Fifteen SP and 13 healthy controls were enrolled. The mean age was 17±0.55 years in SP group and 17±2.23 years in control group. There were no statistically significant differences between the two groups in age. No history of fracture, surgical intervention or immobilization of the knee was noted in the 2 groups. All SP had practiced sports since the age of 10±1.98 years. The number of hours of training was 10±1 hour weekly. The number of participating to competition was 30.86±7.95 yearly. Matches have been played on synthetic turf soccer fields using soccer shoes with plastic cleats in all cases. Physical examination revealed genu varus in 12 cases in SP group versus 6 cases in control group (p<0.005). No ligament instability was found in all cases. In control group cartilage thickness in different sites was: RIA, RMC, LMC, RLC and LLC were 3.32±0.48 mm, 2.61±0.55 mm, 2.59±0.37 mm, 2.6±0.58 mm and 2.7±0.64 mm respectively. RIA, RMC, LMC, RLC and LLC were 3.72±0.64 mm, 2.68±0.32 mm, 2.84±0.45 mm, 2.83±0.45 mm and 2.89±0.39 mm respectively. The cartilage was thicker in SP group in the three sites (p>0.05). The median cartilage thickness in LIA was 3.2±0.55 mm in the group control versus 3.82±0.57 mm in the SP, the difference was statistically significant (p=0.007) Conclusions Our study showed that cartilage thickness can be increased in response to sport especially soccer. Thus, physical activity is associated with an increase in cartilage thickness suggesting that soccer can exert a chondroprotective effect when compared to a sedentary lifestyle. Given that optimizing cartilage health is important in preventing osteoarthritis, these findings indicate that physical activity is beneficial to joint. Our study is consistent with previous study showing a positive relationship between physical activity and tibial cartilage volume. References Donna M. Urquhart, Jephtah F. L. Tobing et al. What is the Effect of Physical Activity on the Knee Joint? Med Sci Sports Exerc. 2011;43(3):432-442. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5362

AB0877 Non Pharmalogical Treatment of Sciatica, A Comparative Study

Background Sciatica is a common disease and can be source of pain and disability. Pharmacological treatment is often prescribed but sometimes adverse effects occur. Acupuncture is an interesting alternative when medical treatment is prohibited. Objectives Our aim was to assess the relation between the pain threshold and therapeutic effects of acupuncture for sciatica. And then to compare the effect of acupuncture in monotherapy or associated with migratory sucker. Methods Fourty patients suffering from sciatica were prospectively screened and devised into 2 groups: G1 treated by acupuncture and G2 treated by acupuncture and migratory sucker. All patients were treated 3 times per week for 20 minutes for a total of 10 sessions. The visual analogical scale (VAS), the straight leg raising test (SLR), and Schober index were assessed at baseline, at the third, sixth and last visit. Results Among patients selected, 38 finished the protocol, 19 both in G1 and G2. The sciatica ran since 42 months [1-168 months] before inclusion. A significant decrease of VAS, SLR was noted for both groups at the end of the study. A significant decrease of distance fingers floor and increase of Schober index was observed only for G2. Comparing the two groups the variation of VAS, SLR, distance fingers floor and Schober index was more important for G2 but it was significant only for distance fingers floor (p<0,05). Conclusions Acupuncture seems to be efficient to treat sciatica, especially when associated to migratory sucker. Since this therapy avoids drugs side effects it should be more considered. References Chen MR. The warming acupuncture for treatment of sciatica in 30 cases. J Tradit Chin Med. 2009. C. Jiao. Current situation and prospects on the clinical researches of traditional acupuncture and moxibustion for sciatica. European Journal of Integrative Medicine 2010. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5216