L. Zakraoui

Associations of vitamin D receptor gene polymorphisms FokI and BsmI with susceptibility to rheumatoid arthritis and Behçet's disease in Tunisians

OBJECTIVES Reports of immunomodulating effects of vitamin D suggest a need for examining allele and genotype frequencies of the vitamin D nuclear receptor gene (VDR) in patients with autoimmune diseases. T-helper-1 (Th1) counts in peripheral blood are increased in both rheumatoid arthritis (RA) and Behçets disease (BD). We studied VDR polymorphisms in patients with these two diseases in Tunisia. METHODS In 108 patients with RA, 131 patients with BD, and 152 controls, we studied FokI and BsmI VDR polymorphisms, using the restriction fragment length polymorphism technique. RESULTS The FokI polymorphism alleles and genotype were significantly more common in the RA group than in the controls (P=0.001 and P=0.005, respectively). The FokI F allele and F/F genotype were significantly associated with BD (P=0.0003 and P=0.002, respectively). Furthermore, in the group with BD, the FokI polymorphism was significantly associated with the presence of vascular manifestations (P=0.006). In patients with RA, the FokI polymorphism was significantly associated with female gender (P=0.003). No significant associations were found between the Bsm1 polymorphism and RA or BD. CONCLUSION The VDR F allele is associated with RA and BD in Tunisians.

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.

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

AB0286 Ultrasound Defined Remission in Tunisian Rheumatoid Arthritis: Table 1.

Background Remission is the principal purpose of treatment in rheumatoid arthritis (RA). Different scores and indices are available to define remission. However, even when the most stringent ones are used, structural damages can occur. The Ultrasonography (US) and especially Power Doppler seems to be the best way to assess true remission and avoid future disabilities. Objectives To assess the association of clinical and/or serological parameters with ultrasound defined remission in RA. Methods A prospective study of 68 Tunisian RA patients was performed. US examination was performed by an experienced rheumatologist blinded to the statue of activity of RA. For each patient 22 joints were scanned: wrists, metacarpo-phalangeal, and proximal interphalangeal joints. A binary score (absence or presence) of synovial hypertrophy/effusion (SH) and power Doppler (PD) signals was applied for each joint. The Sonographic Remission was defined by the absence of PD signals. Visual analogic scale of pain (VAS), Global assessment of disease activity by the patient (GAP), duration of morning stiffness (MS), number of night awakening (NA), tender joint count (TJC), swollen joint count (SJC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and health assessment questionnaires (HAQ) were recorded and compared between patients who were in Sonographic Remission (G1) or not (G2). Results Over the 68 patients recruited, 85% were females. The mean age was 50 years-old [30-70]. Among patients, 30 were diagnosed in remission according to the Disease Activity Score 28 joints and only 13 of them were in remission according to ultrasound. PD signals as a sign of active disease were observed in 53 (78%) patients. Main results are presented in table 1. VAS, GAP and CRP were significantly higher in G2 than in G1. Table 1. Comparison of clinical and serological parameters for patients in ultrasound defined remission or not G1 G2 p VAS 10,6 41,5 0,04 GAP 10,6 43 0,03 MS (minutes) 27,8 0,6 0,06 NA 0 0,9 – CRP (mg/l) 3,2 12,5 0,05 ESR (mm) 21,9 36,2 0,09 HAQ 0,07 1,3 0,08 Conclusions According to our study, sonography-defined disease activity is associated with VAS, GAD and CRP. VAS and GAD, although usually considered as subjective criteria, seem useful for evaluating RA remission. References Vasanth LC. Imaging of rheumatoid arthritis. Rheum Dis Clin North Am 2013 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5159

THU0293 Characteristics of Infectious Spndylodiscitis in Rheumatology

Background Infectious spondylodiscitis is characterized by infection involving the intervertebral disc and adjacent vertebrae. Smaller studies indicate that the incidence of spondylodiscitis is increasing, possible related to expanding elderly and immunocompromised populations, the increasing use of invasive spinal procedures and the use of immunosuppressive therapies. Objectives The aim of this study is to determine the epidemiological, clinical, radiological and bacteriological characteristics of spondylodiscitis in Tunisia. Methods A retrospective study including patients diagnosed as spondylodiscitis in the Rheumatology department between 1995 and 2013. The diagnosis was established basing on bacteriological features or a set of presumption arguments. Results Forty one patients are included in this study. There were 21 males and 20 females. The mean age was 61.66 years, ranged from 25 to 89 years. Predisposing factors were found in 17 patients (41%): diabetes in 8 cases, long-term corticosteroid for chronic inflammatory rheumatism in 4 cases, cirrhosis in 2 cases and chronic renal failure in 3 cases. Duration of symptoms varied from 20 to 90 days. All patients presented with back pain. Fever was noted in 38 cases. A neurological deficit was noted in 7 patients. An increase of erythrocytes sedimentation rate and C-reactive protein was noted in 87% of cases (n=36). Spine X-ray showed a disc space narrowing and irregularity of the end-plates in 39 cases. Lumbar region was the most common infection sites (58%) followed by dorsal spine (32%) and cervical spine (10%). A multi stage spondylodiscitis was found in 4 cases. Only 27 patients had MRI showing epiduritis in 12 patients and paravertebral abscess in 8 patients. Spndylodiscitis was associated with a septic arthritis in one case and Tuberculosis spondylodiscitis was associated with hepatic tuberculosis in another case. The causative microorganism was identified in 25 cases (61%): staphylococcuc in 4 cases, Gram negative germ in 5 cases, streptococcus in 3 cases, mycobacterium tuberculosis in 12 cases and brucella in 4 cases. Multi-bacterial spondylodiscitis was found in 2 patients. All patients underwent initially adapted antibiotics and immobilization leading to recovery in 73% of cases (n=30). Seven patients were lost during follow up. Neurological complication occurred in 3 cases and sepsis in 1 case. Conclusions Infectious spondylodiscitis necessitate a high index of suspicion in a patient presenting with significant back pain and laboratory evidence of an acute inflammatory process. The diagnosis is based on symptoms, clinical findings, and imaging and laboratory results. MRI remains the most sensitive radiological examination for early detection of spondylodiscitis. Identifying the germ incriminated in infectious spondylodiscitis is imperative. Early diagnosis is necessary to avoid life threatening complications and neurological squeals. References Lucy Cottle, Terry Riordan. Infectious spondylodiscitis. Journal of Infection 2008; 56: 401–412 Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.5428

AB0783 Ultrasonography Lesions in Tunisian Hand Osteoarthritis

Background Hand osteoarthritis (HOA) is one of the three most common subsets of osteoarthritis. So far, HOA diagnosis has relied on clinical (pain and finger joint nodes) and radiological features. Conventional radiographs (CR) can assess only subchondral bone. However, ultrasound (US) could detect synovial inflammation, even in the absence of clinically detectable signs of inflammation. Objectives To describe ultrasound abnormalities in HOA in order to assess eventual association between these lesions and clinical symptoms. Methods Patients at a hospital-based outpatient rheumatology clinic who met American College of Rheumatology criteria [1] for HOA were included. Demographic and clinical data (Visual analogue scale (VAS), the Australian Canadian osteoarthritis hand index (AUSCAN) pain, tender and swollen joint count) were collected for each patient. Ultrasonography (Esaote MyLab 60 machine and a 13-18 MHz linear array transducer) and plain radiographs of the hands were performed in all participants. The sonographer was a rheumatologist with theoretical and practical training in musculoskeletal ultrasonography and blinded to clinical features. The following joints were assessed: metacarpophalangeal (MCP) 1–5, proximal interphalangeal (PIP) 1–5, distal interphalangeal (DIP) 2–5 and trapezio-metacarpal (TM) joints. Allover, 720 joints were explored. In B mode, erosion, synovial hypertophy and effusion were defined with the OMERACT criteria. In power Doppler mode, the inflammatory activity was evaluated. Results We included 24 women with symptomatic HOA between July and December 2013. Their mean age was 59,6 years (range, 44-76). All participants were right-handed. Median VAS and AUSCAN pain were 38mm and 7,5, respectively. Mean Dreiser algofunctional index was 8.03±6 (range, 1-19). Their mean symptom duration was 5 years (range, 1-20years), it consists in pain in 21 cases and stiffness in 8 cases. Mean number of Heberdens and Bouchards nodes were 3,8 (±2,9) and 1.5 (±1,8), respectively. The average number of painful joint was either spontaneously at 2,08 (±5,45) or upon squeezing at 3.58 (±6,3) and with swelling at 0,33 (±0,7). Erosions were detected in 89/720 (12.3%) small joints by US and in 152/720 (24%) small joints by CR (p=0,005). Osteophytes were detected in 137/720small joints by US, and in 159/720small joints by CR (p=0,5). Thickened synovium was found in 22/720, effusion in 79/720 and increased power Doppler in 14/720small joints. Effusion were distributed between the PIP (91%) and DIP (9%), synovites between PIP (n=3), DIP (n=8), TM (n=7) and power Doppler imaging between PIP (n=3), DIP (n=6) and TM (n=5). The number of tender joint was significantly correlated with presence of an effusion by US (r =0.49, p<0.0001) but not correlated with a positive Doppler signal (r=-0.12, p=0.02). Conclusions Our study showed that effusion is correlated with the number of tender joint. US detect inflammatory changes in small hand joints in the vast majority of patients with HOA. It suggests that current treatment modalities are inadequate treatment for this disease References Altman R, Alarcon G, Appelrouth D, et al. The American Rheumatology critera for the classification and reporting of the hand 1990;33:1601–10. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5954