C. Duarte

Alkyl Group Effect on the Conformational Isomerism of trans-2-Bromoalkoxycyclohexanes Analyzed by NMR Spectroscopy and Theoretical Calculations

Suitable (3)J(H,H) coupling constants and theoretical calculations were used to define the conformational preferences of trans-2-bromoalkoxycyclohexanes (alkoxy = OMe, OEt, O(i)Pr, and O(t)Bu) for the isolated molecule and as a function of the medium. The diaxial conformer was preponderant, or at least similarly populated to the diequatorial form, for the tert-butoxy derivative only, while the diequatorial conformer was prevalent for the remaining alkoxy derivatives (except for the OMe derivative in CCl(4) solution). The conformational behavior of these compounds was analyzed on the basis of classical steric effects and attractive electron delocalizations, by means of natural bond orbital analysis.

Coexisting primary Sjögren’s syndrome and sarcoidosis: coincidence, mutually exclusive conditions or syndrome?

Herein, we describe a 44-year-old female diagnosed with histologically proven coexistence of primary Sjögren’s syndrome and sarcoidosis with pulmonary and muscular involvement. The differential diagnosis may be difficult, but this is not an exceptional case, which highlights the need to critically revise the consideration of sarcoidosis as an exclusion for primary Sjögren’s syndrome, as established in current classification criteria.

Conformational analysis of 2,2-difluoroethylamine hydrochloride: double gauche effect.

Summary The gauche effect in fluorinated alkylammonium salts is well known and attributed either to an intramolecular hydrogen bond or to an electrostatic attraction between the positively charged nitrogen and the vicinal electronegative fluorine atom. This work reports the effect of adding a fluorine atom in 2-fluoroethylamine hydrochloride on the conformational isomerism of the resulting 2,2-difluoroethylamine chloride (2). The analysis was carried out using NMR coupling constants in D2O solution, in order to mimic the equilibrium conditions in a physiological medium, in the gas phase and in implicit water through theoretical calculations. Despite the presence of σCH→σ*CF and σCH→σ*CN interactions, which usually rule the hyperconjugative gauche effect in 1,2-disubstituted ethanes, the most important forces leading to the double gauche effect (+NH3 in the gauche relationship with both fluorine atoms) in 2 are the Lewis-type ones. Particularly, electrostatic interactions are operative even in water solution, where they should be significantly attenuated, whereas hyperconjugation and hydrogen bond have secondary importance.

Theoretical and infrared studies on the conformational isomerism of trans-2-bromo-alkoxycyclohexanes

The infrared spectra of trans-2-bromo-alkoxycyclohexanes (alcoxy = OMe, OEt, O(i)Pr and O(t)Bu) were obtained for the neat liquid, and the C-Br stretching mode was quantitatively analyzed to give insight about the conformational isomerism of these compounds. Frequency calculations supported the band assignments, and the relative band intensities suggest that the diaxial conformer is prevalent for the methoxy and tert-butoxy derivatives (51 and 56%, respectively), while the diequatorial form is preponderant for the ethoxy and isopropoxy derivatives (76 and 77%, respectively). Therefore, the size of the alkoxy group plays a determinant role in determining the conformational preferences of the title compounds.

FRI0748-HPR Cross-cultural validation of the portuguese “rheumatoid arthritis impact of disease” score: cross-sectional study

Background The Rheumatoid Arthritis Impact of Disease (RAID) score1 assesses 7 impact domains of interest for people with rheumatoid arthritis (RA). Its use in research and clinical practice has been growing, and it is already translated into over 70 languages2 but the cross-cultural validity of the Portuguese RAID has not been well established. Objectives To validate the Portuguese RAID for use in Portugal. Methods This was a single centre, cross-sectional validation study involving 2 phases: (i) cognitive debriefing with 38 patients to determine comprehension of the existing2 Portuguese RAID (ii) cross-cultural validation using data from adult patients who were willing and able to complete the Portuguese RAID unaided. Analyses included fit to the Rasch model (implying construct validity, reliability and statistical sufficiency), tests for unidimensionality and invariance across different patient subgroups i.e. age, gender, education background, disease duration, function and culture. To test invariance to culture, the Portugal dataset was compared with datasets from France (n=195) and the UK (n=205).3 RUMM2030 software was used in all analyses. Results Phase I led to minor changes in phrasing 3 items to enhance understanding and conceptual equivalence between the original RAID and the Portuguese version. In Phase II, 288 patients were included: mean (SD) age=60 (12) years, 82% females, 76% with disease duration ≥5 years, 30% on biologics. The Portuguese RAID was shown to have adequate fit to the Rasch model and high internal consistency (Table 1). Unidimensionality and invariance to age, gender, disease duration and function were confirmed (data not shown). The scale was well targeted for patients with different levels of disease impact (Figure 1). Pooling the datasets from Portugal, France and the UK revealed no cultural response bias (Table 1). RAID was then calibrated into logit-based scores to enable parametric analyses and bias-free cross-cultural comparisons if desired (data not shown).Table 1. Results of Rasch analysis from pooled data Country N RAID Fit Residual Chi2 Interaction Person Separation Index (n items) Mean (SD) Item Person Value (DF) p-value Portugal 288 7 -0.13 (2.53) -0.67 (1.60) 40.50 (35) 0.24 0.94 UK 205 7 0.22 (1.72) -0.44 (1.37) 40.50 (35) 0.17 0.93 France 195 7 0.19 (1.99) -0.71 (1.57) 25.69 (21) 0.22 0.91 Pooled 688 7 -0.06 (3.48) -0.65 (1.55) 94.88 (63) 0.01 0.93 6* -0.34 (3.88) -0.63 (1.44) 66.04 (54) 0.13 0.93 Expected values for perfect fit 0 (1) 0 (1) >0.05 >0.85 DF, degrees of freedom; *6 items for cross-cultural comparisons (items 2 “Function” and 5 “Physical well-being” combined). Conclusions This study confirms the Portuguese RAID as a robust unidimensional tool for use in Portugal. The raw scores of the 7-item RAID can be used with confidence in clinical practice. Conversion charts are available to enable accurate cross-cultural comparisons across Portugal, France and the UK. References Gossec L, et al. Ann Rheum Dis, 2011;70:935–42. EULAR RAID and PsAID Questionnaires. Available from http://www.eular.org/tools_products_.cfm Accessed 25th Jan. 2017. Hewlett S, et al. Ann Rheum Dis, 2015;74:Suppl 2:559. Disclosure of Interest None declared

Endocyclic Oxygen in 3-Fluorodihydro-2H-pyran-4(3H)-one That Does Not Induce the Gauche Effect

2-Fluorocyclohexanone undergoes chair inversion, giving rise to axial and equatorial conformers, with the equatorial form being highly preferred in solution, for example, 87% in chloroform and 93% in methylene chloride. Modifications in the conformational preferences can modify macroscopic properties of 2-fluoro ketones. The introduction of an endocyclic oxygen in 2-fluorocyclohexanone to give 3-fluorodihydro-2H-pyran-4(3H)-one would be expected to create a gauche effect in the axial conformer along with the O-C-C-F moiety, inducing an increase of its population. However, small changes were verified in the conformational populations both in the gas phase and solution because the carbonyl group plays an important role for the hyperconjugation in the equatorial conformer, despite experiencing strong dipolar repulsion with the fluorine atom. These data were obtained theoretically and by NMR spectroscopy, while the nature of the interactions governing these conformational shifts were investigated on the basis of natural bond orbital analysis.

THU0602 Patient Global Assessment in Rheumatoid Arthritis Conveys A Variable Blend of Disease Activity and Disease Impact: A Cross-Sectional Study with 311 Patients

Background Patient global assessment (PGA) is a key outcome measure in rheumatoid arthritis (RA) and the sole patient-reported outcome included in measures currently used to guide treat-to-target (T2T) strategies. However, it is still not clear which concepts it conveys and how appropriate they are to guide therapy. Objectives to explore the meaning of PGA in RA patients, namely the influence of disease activity, disease impact, comorbidities, and psychological aspects. Methods This was an observational, cross-sectional study including consecutive RA patients (ACR/EULAR 2010 or ACR 1987 criteria) followed in a tertiary rheumatology outpatient department. Data collection included PGA (100mm VAS), pain and fatigue (0–10 NRS), Health Assessment Questionnaire (HAQ), Functional Assessment of Chronic Illness Therapy (FACIT), Hospital Anxiety and Depression Scale (HADS), Happiness Subjective Scale (HSS), and Ten Item Personality Inventory (TIPI). Demographic data, comorbidities, and disease activity [tender joint (TJC28) and swollen joint counts (SJC28), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)] were also collected. Disease activity categories were defined as: 1) remission (ACR/EULAR 2011 boolean-based definition), 2) near-remission (only PGA>1), and 3) non-remission. Univariate (Pearson correlation, students t test and One Way ANOVA) and multivariable analysis (linear regression, with stepwise methods and assessment of multicolinearity) were performed to explain PGA. Results 311 patients were included (82% females, 60±12 years, 11±9 years of disease duration, 8±5 years of formal education and a mean DAS(28)CRP4v = 2.9±1.2). All comorbidities assessed were associated with statistically (p<0.05) higher PGA than RA alone (Graph 1). PGA was statistically correlated with all predictor variables, except for the personality domain “agreeableness”. In multivariable analysis, PGA was explained (R2adj.=0.58) by pain (β=0.33), fatigue (β=0.23), function (β=0.21), anxiety (β=0.13), and SJC28 (β=0.09). The predictors of PGA were different between disease activity categories (Table 1).Table 1. Multivariable linear regression models (stepwise-backward method) to explain PGA in RA patients Variable Patients (β adjusted*) All (n=281) Remission (n=120) Near-misses (n=19) Non-remission (n=152) Pain 0.33 0.35 0.28 Fatigue 0.23 0.44 0.72 HAQ 0.21 0.30 HADS-Anxiety 0.13 0.19 SJC28 0.09 0.12 TJC28 0.20 0.45 CRP −0.31 R2 adj. 0.58 0.57 0.78 0.55 *All with p<0.05. Conclusions PGA does not only convey the inflammatory activity of the disease but also pain (of whatever musculoskeletal origin), fatigue, functional capacity, and psychological variables. These predictors present different relative impacts in different disease activity categories. In near-misses, the group where PGA is decisive for T2T, PGA is determined by fatigue, TJC28 and negatively associated with CRP. Including PGA in composite indices drifts these measures away from strict disease activity representation. This may negatively affect the adequacy of target-driven decisions regarding immunosuppressive therapy, inherently designed to control inflammation. Disclosure of Interest None declared

A1.10 Human bone marrow-derived mesenchymal stromal cells strongly inhibit cytokine production by naive, memory and effector CD4+ and CD8+ T cells from rheumatoid arthritis patients, independently of disease activity status

Background and objectives Rheumatoid arthritis (RA) is a chronic inflammatory disease characterised by autoimmune activation leading to local and systemic consequences. Self-reactive T cells play a decisive role in the initiation and maintenance of the disease process. This disease course has been deeply modified by disease-modifying anti-rheumatic drugs that block pro-inflammatory cytokines, but still more than 1/3 of patients do not respond adequately to treatment. To overcome this limitation, mesenchymal stromal cells (MSC) based therapies have been recently explored. MSC are a population of adult non-hematopoietic stem cells with the ability to immunomodulate different cells of the immune system. The aim of this study was to verify the immunomodulatory activity of bone marrow (BM)-derived MSC on peripheral blood helper (Th) and cytotoxic T cells (Tc), distributed among their different functional compartments (naïve, central memory, effector memory and effector) from RA patients and healthy individuals. Materials and methods To this purpose we preformed co-cultures with mononuclear cells and BM-MSC from 12 RA patients and 8 controls during 20 h in a ratio of 2:1 (MNC:BM-MSC). Then, T cells were activated with PMA and ionomycin for 4 h to induce cytokine production by T cells. The frequency of Th and Tc cells producing cytokines (IL-2, IFN-γ, TNF-α, IL-6, IL-17 and IL-9) among the different functional compartments was measured by flow cytometry. Moreover, IL-4, IL-10, TGF-β and CTLA-4 mRNA expression was assessed after cell sorting of CD4+ and CD8+ T cells. Results BM-MSC clearly induced a decrease in the frequency of CD4+ and CD8+ T cells producing pro-inflammatory cytokines (for all the cytokines analysed) in all functional compartments and in both groups under study. However, the intensity of inhibition varied with the cytokine and the T cell functional compartment. Regarding the mRNA expression, in the presence of BM-MSC, we observed an increase of IL-4, IL-10, TGF-β and CTLA-4 in purified CD4+ T cells for both groups, although in a lower extent in RA patients. Likewise, BM-MSC induced an augment of mRNA levels of the abovementioned molecules in CD8+ T cells, although a more pronounced mRNA expression was observed in RA patients, excepting for IL-4, which expression decreased in both groups. Conclusions Our data show that BM-MSC effectively inhibit pro-inflammatory cytokines production by Th and Tc in all functional compartments and increase the mRNA expression of anti-inflammatory molecules in both T cell subpopulations. These results support their potential utility in the treatment of autoimmune diseases.

OP0031 Tocilizumab is Associated with Higher CDai/Sdai Remission in Biologic-Naïve Rheumatoid Arthritis Patients – Data from Reuma.Pt

Background Tocilizumab (TCZ), an interleukin-6 receptor blocker, and anti-tumor necrosis factor (TNF) biologic agents are key therapies in the management of rheumatoid arthritis (RA). They are considered to be equally effective and very few head-to-head comparisons have been published. Objectives To compare remission rates in RA patients treated with anti-TNF agents and TCZ and assess the impact of previous biologic therapies in treatment response. Methods We included RA patients registered in the Rheumatic Diseases Portuguese Register, Reuma.pt, who started anti-TNF or TCZ after January 1, 2008, were treated for at least 6 months and had available DAS28 scores at baseline and at 6 months. Our primary outcome was the proportion of patients who achieved remission at 6 months by DAS28, CDAI, SDAI and Boolean remission criteria. Logistic regressions were performed to compare the groups and subgroup analyses of biologic-naïve patients were conducted. Results 524 RA patients were enrolled, (106 adalimumab, 202 etanercept, 43 golimumab, 78 infliximab, 95 TCZ). At baseline, the groups were similar except for proportion of biologic-naïve patients (lower in TCZ group, p<0.0001) and mean DAS28, CDAI and swollen joint count, all higher in the TCZ group (respectively: p=0.0005, p=0.037 and p<0.0001). At 6 months, more TCZ-treated patients were in DAS28 remission, with no differences for CDAI, SDAI or Boolean remission. Considering only naïve patients, DAS28, CDAI and SDAI remission were significantly higher in the TCZ group compared to anti-TNF, with similar rates of Boolean remission. This was confirmed in the multivariate logistic regression, adjusting for age, gender, number of previous biologics and baseline disease activity: DAS28 OR 10.8 (5.9-19.7), CDAI OR 2.9 (1.3-6.5), SDAI OR 4.1 (1.8-9.5), Boolean OR 1.9 (0.88-4.3). Table 1. Proportion of patients in remission according to different criteria and biologic class Anti-TNF Tocilizumab OR (95% CI) Overall Population  DAS28 (n=524) 102/429 (23.8) 55/95 (57.9) 4.4 (2.8–7.0)  CDAI (n=327) 36/260 (13.9) 14/67 (20.9) 1.6 (0.8–3.2)  SDAI (n=298) 33/239 (13.8) 14/59 (23.7) 1.9 (0.97–3.9)  Boolean (n=468) 42/358 (11.7) 11/83 (13.3) 1.1 (0.6–2.3) Biologic-naïve patients  DAS28 (n=417) 89/365 (24.4) 37/52 (71.2) 7.7 (4.0–14.5)  CDAI (n=258) 33/223 (14.8) 11/35 (31.4) 2.6 (1.2–5.8)  SDAI (n=237) 32/206 (15.5) 11/31 (35.5) 2.99 (1.33–6.76)  Boolean (n=348) 36/302 (11.9) 8/46 (17.4) 1.6 (0.7–3.5) Conclusions TCZ treatment was associated with higher rate of DAS28 remission at 6 months and previous biologic therapy significantly affected CDAI/SDAI remission. Naïve patients treated with TCZ had better DAS28, CDAI and SDAI remission rates compared to those treated with TNF inhibitors, whereas the more stringent Boolean remission was similar among all groups. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2668

AB0451 Changes in DAS28, CDAI and SDAI are Associated with Biologic Class, Gender, Previous Biologic Therapy and ACPA/RF Status – Results from Reuma.PT

Background Tocilizumab (TCZ) and anti-tumor necrosis factor (TNF) biologic agents are key therapies in the management of rheumatoid arthritis (RA). They are considered to be equally effective and very few head-to-head comparisons have been published. Objectives To compare response to therapy in RA patients treated with anti-TNF agents and TCZ according to different response measures and determine the factors influencing it. Methods We included RA patients registered in the Rheumatic Diseases Portuguese Register, Reuma.pt, who started anti-TNF or TCZ after January 1, 2008, were treated for at least 6 months and had available DAS28 scores at baseline and at 6 months. Our primary outcome was the change in DAS28, CDAI and SDAI at 6 months. We performed linear regressions to compare the groups and determined the best model predicting change in disease activity for each index. Results 524 RA patients were enrolled, (106 adalimumab, 202 etanercept, 43 golimumab, 78 infliximab, 95 TCZ). At baseline, TCZ users were less frequently naïve to biologic therapies (54.7% vs. 85%, p<0.0001), had more swollen and tender joint counts (p<0.0001 and p=0.02, respectively) and higher disease activity according to all indexes: DAS28 6.1±1.1 vs. 5.4±1.3 (n=524, p<0.0001), CDAI 33.3±13.2 vs. 28.1±13.6 (n=376, p=0.005), SDAI.35.6±13.1 vs. 29.1±30.4 (n=361, p=0.004). At 6 months, change in DAS28, CDAI, SDAI and joint counts was significantly higher in the TCZ group (Table 1). Multivariate linear regression models best predicting change in disease activity included biologic class, number of previous biologics, baseline activity, gender and ACPA/RF status (Table 2). Compared to anti-TNF, TCZ was associated with a larger difference in ΔDAS28, ΔCDAI and ΔSDAI of, respectively, 1.45, 4.25 and 5.41. Table 1. Baseline and change in disease activity according to biologic class (Mann-Whitney test) Change at 6 months Anti-TNF (n=429) Tocilizumab (n=95) p-value ΔDAS28 1.8 (1.4) 3.3 (1.6) <0.0001 ΔCDAI (n=327) 16.0 (13.6) 22.7 (15.7) 0.0003 ΔSDAI (n=298) 17.1 (14.8) 25.2 (16.5) 0.0001 ΔSJC 4.7 (4.8) 7.8 (6.6) <0.0001 ΔTJC 6.4 (7.2) 8.7 (7.7) 0.005 Table 2. Multivariate linear regression models predicting 6-months change in disease activity ΔDAS28 (n=524) ΔCDAI (n=286) ΔSDAI (n=260) Adjusted-R2 0.391 0.613 0.559 Covariables β-coefficient (p) β-coefficient (p) β-coefficient (p) Biologic class (TCZ) 1.45 (<0.0001) 4.25 (0.004) 5.41 (0.003) No. previous biologics −0.41 (<0.0001) −2.47 (0.002) −2.78 (0.004) Baseline activity 0.54 (<0.0001) 0.79 (<0.0001) 0.77 (<0.0001) Female gender −0.40 (0.02) −1.74 (0.29) −1.64 (0.41) ACPA/RF positivity −0.45 (0.004) −3.65 (0.01) −4.77 (0.008) Conclusions TCZ treatment was associated with greater change in DAS28, CDAI, SDAI and joint counts at 6 months. Biologic class, number of previous biologics, baseline activity, gender and ACPA/RF status predicted change in disease activity. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3414