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Background: Remission/low disease activity (LDA) are the main treatment goals in rheumatoid arthritis (RA) patients. Several independent predictors of RA remission had been described, namely: baseline clinical and laboratory characteristics and genetic markers. Vastesaeger N. et al published 2 tools that showed the ability to predict golimumab treatment outcomes in patients with RA. These matrices are based on a combination of 6 baseline characteristics (Gender, presence/absence of comorbidities, age, HAQ, ESR and TJC28) and may provide guidance for the selection of candidates for anti-TNF therapy. Objectives: To estimate the real-world accuracy of two quantitative tools to predict RA remission and low disease activity. Methods: Multicentric, retrospective, observational study, using data from the Rheumatic Diseases Portuguese Register (Reuma.pt), including biologic naïve RA patients under anti-TNF therapy as first line biologic with at least 6 months of treatment. The accuracy of these matrix tools was assessed by likelihood-ratio (LR), sensitivity (SN), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC). Results: 674 RA patients under anti-TNF therapy as first line biologic were included, from 12 centers (266 etanercept, 186 infliximab, 131 adalimumab, 85 golimumab, 6 certolizumab pegol). The median (min-max) age of our sample was 53.4 (18.4-82.3) years and the median disease duration (min-max) was 7.7 (0-42.5) years. The majority were female (72%). Most of them had RF and/or ACPA positivity (75.5%) and erosive disease (54.9%); 58.6% had comorbidities. At baseline, median (min-max) disease actity related values were: ESR 31 (1-120) mmh, C-RP 1.14 mg/dL (0.01-46.4), SJC28 7 (0-28), TJC28 10 (0-28) and PGA 62 (0-100). The median DAS28 ESR was 5.57 (1.13-8.43) and the median HAQ was 1.5 (0-3). At 6-months, 157 (23.3%) patients achieved remission (DAS28 ESR ≤ 2.6) and 96 (14.2%) LDA (DAS28 ESR > 2.6 and ≤ 3.2). Accuracy of the equation, schematically represented by matrix tools, to predict remission and LDA was measured with ROC curves. Area under the curve for remission in this real world sample was 0.7556 [IC 95% (0.7127-0.7985)] and for LDA was 0.5480 [IC 95% (0.4915 -0.6046)]. SN, SP and LR vary depending on cut-offs applied for percentages obtained by this equation model. The highest, LR (8.23) for remission state was obtained at a cut-off ≥ 67%, with high SP (99.6%) but low SN (3.2%). A better balance of SN and SP (65.6% and 73.9%, respectively) was observed for a cut-off >30%, with a LR of 2.51, PPV of 43.3% and NPV of 87.6%. Conclusion: The accuracy of the tool for prediction of LDA states is not as good as for remission. Still, our results corroborate the idea that these matrix tools could be helpful to select patients for anti-TNF therapy. [ABSTRACT FROM AUTHOR]

Background: Symptomatic compression neuropathy of the median nerve is a frequently encountered clinical entity. The most common cause of the median nerve compression is carpal tunnel syndrome (CTS) due to thickening of the anterior annular ligament. Nerve compression by anomalous masses located at the wrist and distal forearm is an infrequent condition. Accessory muscles and other masses, like lipomas, may compress underlying structures in the carpal tunnel region, causing pain and paresthesias, which leads to diagnosis of CTS, which can mislead to a wrong diagnosis of thickening of the anterior annular ligament. Clinical cases: We present three cases of patients with symptomatology and clinical tests (Tinel's and Phalen's) compatible with compression of the median nerve in the carpal tunnel that presented, on clinical examination, a soft tissue swelling in the proximal region of the forearm. The ultrasound (US) evaluation revealed an hypoechoic masse, of different aethiologies, that compressed the median nerve. Clinical case 1: A 31 years old woman, whose electromyogram showed sensory latency of the left median nerve in the wrist, compatible with slight CTS. The soft tissue swelling, corresponded, in US evaluation, to an accessory muscle. An MRI showed a "muscle mass, which may correspond to the anatomical variant at this level and the median nerve shows a slight hypersignal proximal to the carpal tunnel." A surgical exploration of the carpal tunnel was performed, with a median anterior approach of the wrist, extended proximally, with identification and release of the median nerve and excision of exuberant muscular belly that corresponded to an accessory flexor digitorum superficialis indicis. In a two months follow-up the patient presented resolution of complaints of paresthesia and neuropathic pain. Clinical case 2: A 43 years old woman, with normal nerve conduction in electromyogram. On US evaluation, the swelling on the dorsal flexor surface corresponded to an hypoechoic mass. The MRI revealed "muscular groups of the volar surface of the distal forearm with questionable mild hypersignal of the pronator quadratus, which may translate interference with the enervation or resulting from overuse". The surgical exploration revealed a lipoma. Clinical case 3: A 45 years old woman, with a normal electromyogram. The soft tissue swelling corresponded, in US evaluation, to an hypoechoic mass that compressed the median nerve, suggestive of lipoma or muscle mass. The patient is awaiting surgical exploration for median nerve liberation. Discussion: CTS is one of the most common peripheral neuropathies in the upper extremity and is defined as an entrapment syndrome of the median nerve at the level of the distal forearm. Median nerve compression at the wrist can also be the result of an accessory flexor tendon or hypertrophic muscles. Although rare, these anatomic variances need to be considered, especially when a swelling in the proximal region of the forearm is visible, like in ours cases. Lipomas are the most frequent human tumours and are generally asymptomatic, however, like in our second case, they can compress some structures like nerves. The cases of accessory muscles and other masses described in the literature as causes of median nerve compression are mostly described in patients that maintained residual clinic after the surgical decompression of the carpal tunnel. Careful examination with an US evaluation prior to surgery may help to identify these cases and help planning and directing surgical approach. [ABSTRACT FROM AUTHOR]

Introduction: More than 90% of the cases of septic arthritis are monoarticular. The infection of a joint can occur through several mechanisms: by hematogenic dissemination; contiguity; surgical contamination; direct inoculation; or trauma. Neisseria gonorrhoeae, Staphylococcus and Streptococcus spp are the most frequent etiological agents. Clinical case: A 69-year-old male, previously healthy, presents with an acute case of pain and swelling of the left sternoclavicular joint and posteriorly in the right ankle and the first left interphalangeal (IP). He went several times to Emergency Department and was medicated with non-steroid anti-inflammatories, analgesics, large spectrum antibiotics and corticosteroids, without improvement. After a Rheumatology consultation he was admitted to the ward. He denied history of fever or nocturnal sudoresis. Musculoskeletal ultrasonography was performed and an arthrocentesis of the first IP was made, the synovial fluid was sero-hematic, with some whitish spots. The polarized light microscope observation was negative for crystals and the samples were sent to bacteriological and mycobacteriological studies. In the 5th day of hospitalization he began fever and aggravation of the general state, so we took blood cultures. At this time the results of the bacteriological study of synovial fluid were known: Staphylococcus aureus. The patient was started on vancomycin. An MRI was performed directed to the sternoclavicular articulation and later MRI of the pelvis. Both suggested infectious aetiology with multiple abscessed collections. Imunodeficiencies were excluded, and the patient has had a good outcome. Discussion: The case presented has special clinical relevance due to its atypia. It is a healthy patient with no known risk factors for septic arthritis, no known comorbidities (including diabetes mellitus, or immunemediated diseases), without usual medication, with no history of recurrent infections that may suggest any degree of immunosuppression. The patient had no surgical interventions or previous intravenous drug use or recent trauma and also no history of skin infections. Also atypical is the polyarticular involvement and also the lack of fever as one of the cardinal signs of infection, which contributed to the diagnosis and treatment delay. [ABSTRACT FROM AUTHOR]

Background: Sjögren syndrome (SS) is a systemic inflammatory autoimmune disease that primarily affects exocrine organs leading to sicca symptoms. It can be classified as primary SS (pSS) when is not related to other rheumatic diseases, or as secondary SS (sSS) when it is related to other immune-mediated disease. Hepatitis C Virus (HCV) has been associated with many extrahepatic manifestations and increased HCV-related morbidity due to cryoglobulinemia vasculitis, lymphoma, arthralgia, myalgia, and sicca syndrome. Sicca symptoms have been reported in 10 to 30% of HCV-infected patients, whereas a definite SS is reported in less than 5%. Notwithstanding, active HCV infection is considered an exclusion criterion in ACR/EULAR 2016 classification criteria for pSS, a highly debated topic, mainly because HCV is viewed as an ethiopathogenic factor for SS onset. Clinical case: A 48-year-old woman with a known HCV chronic infection and discoid lupus with more than 10-year evolution, presented in our Rheumatology department with xeropthalmia, xerostomia and episodic parotid enlargement with 5-year-duration. Recently, she presented with right gonarthritis. Ophthalmic evaluation with lissamine green dye and tear breakup time test confirmed xeropthalmia. Serology analysis revealed low C3 and C4, slightly elevated IgM and Rheumatoid factor (RF). Anti-SSA antibody was positive. Both antinuclear antibody (ANA) and anti SSB antibody were negative. Inflammatory parameters (erythrocyte sedimentation rate - ESR - and C reactive protein - CRP) were normal. Cryoglobulins were negative. Salivary glands ultrasonography (US) revealed enlargement of submandibular glands. Salivary gland biopsy was normal. Polymerase chain reaction (PCR) for HCV-RNA in 2015 was positive. This analysis was repeated in 2018 and it was negative. Discussion: Distinction between pSS and HCV-induced SS (HCV-SS) might be troublesome. SS-related markers that can occur in HCV infection are sicca symptoms with sialadenitis with positive biopsy (25%), which can lead to false pSS diagnosis. ANA are positive in 20-35% of the HCV-infected patients. Regardless, some clinical and immunological aspects might help differentiate both situations. Studies reported that patients with HCV-SS are usually older, more frequently male individuals, have more frequently positive RF, cryoglobulinemia, and hypocomplementemia; on the other hand, have less frequently parotid enlargement, anti-SSA, and SSB antibodies (3-4%). Arthralgias are frequent in HCV-infected patients, especially if cryoglobulinemia vasculitis is present (40-80%), but arthritis is rare (<5%). Regarding the reported case, there are some misleading aspects. The patient presented sicca symptoms with hypocomplementemia and positivity to RF, common features in HCV-SS, while cryoglobulinemia was absent. Nevertheless, she fulfilled pSS classification criteria (positive anti-SSA antibody, ocular staining score superior to 5 and negative PCR for HCV-RNA). While the presence of arthritis and discoid lupus supports a primary rheumatic disease, normal inflammatory parameters, negative ANA and salivary biopsy are less frequent in pSS. In conclusion, HCV-infected patients may present sicca symptoms and differentiating the two entities - HCV-SS and pSS - might be difficult. We describe a clinical scenario where an HCV-infected patient with mixed characteristics between pSS and HCV-SS, fulfilled pSS ACR-EULAR 2016 classification criteria and HCV RNA is untraceable by PCR technique. [ABSTRACT FROM AUTHOR]

Background: The Patient's Global Assessment of Disease Activity (PtGA) and Physician's Global Assessment of Disease Activity (PhGA) are important measures in treat to target strategy in rheumatoid arthritis (RA), but often provide discordant results. (1,2) Both PtGA and PhGA are assessed as part of three commonly used measures of disease activity (Disease Activity Score (DAS-28), in Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI)). Objective: To assess differences and determinants of PtGA and PhGA in RA patients under biologic treatment. Methods: A cross-sectional study, including 60 patients with RA, diagnosed according to the ACR/EULAR criteria treated with biological therapy. Participants completed 36-Item Short Form Health Survey (SF-36), Health Assessment Questionnaire (HAQ) and visual analogue scale (VAS) for global disease severity and pain. The physician completed the VAS for global disease severity and evaluated the parameters of inflammatory activity (sedimentation rate (SR) and C-reactive protein (CRP), Activity Score (DAS28). SPSS was used for the statistical analysis, significance level was 2-sided p<0.050. Results: Among the 60 patients included, 73.3% were female, with a mean age of 57.1 years old (SD=11.5) and mean disease duration of 18.1 years (SD=8.5). Clinical and laboratory characteristics of the patients are shown in Table I. Positive discordance (PtGA>PhGA, more than 25mm in VAS) was found in 51.7% of cases. PtGA (median: 41.5, IQR: 26.3) and PhGA (median: 5.0, IQR: 20) was significantly diffe rent (p<0.001). PtGA correlated with pain VAS (P=0.795, p<0.001), swollen joints (P=0.311, p=0.016), painful joints (P=0.288, p=0.025), HAQ (P=0.570, p<0.001), and negatively correlated with SF-36 physical and mental health summary scales (P=-0.444, p<0.001 and P=-0.470, p<0.001, respectively). These variables, in linear multiple regression represented a R2=0.702. The main predictors of PtGA were pain VAS and HAQ. PhGA correlated with: pain VAS (P=0.372, p=0.003), swollen joints (P=0.834, p<0.001), painful joints (P=0.777, p<0.001), and negatively correlated with SF-36 physical and mental health summary scales (P= -0.337, p=0.009 and P=-0.273, p=0.025, respectively). Patients with elevation of CRP had bigger PhGA (p=0.014). In linear multiple regression, these variables, represented a R2=0.722. The main predictors of PhGA were swollen joints and CRP level. Conclusions: In this study, we show the variability implied on global assessment of RA activity. On one hand, patient-reported outcomes are constrained to subjective experience of pain and function. On the other, physicians attend to more objective measures such as swollen joints and CRP. To the best of our knowledge, we demonstrate a correlation of both PtGA and PhGA with SF-36 scales, a new data in the literature. [ABSTRACT FROM AUTHOR]

Background: Primary Sjögren's syndrome (pSS) is a multisystem immune-mediated disease characterized by hypofunction of salivary and lacrimal glands and possible multi-organ systemic manifestations. Over the past years, three sets of diagnostic criteria have been proposed, but none included salivary gland ultrasound (SGUS) (1). However, SGUS has been recently applied for diagnosis and there are some reports regarding the correlation of SGUS findings with immunological and serological features in pSS patients (2, 3). Objective: To investigate the association of SGUS findings with clinical and analytical features of pSS patients. Methods: A total of 54 patients diagnosed with pSS, fulfilling both the 2016 ACR/EULAR and 2002 AECG criteria for the disease, followed-up at our Rheumatology department, underwent SGUS evaluation of salivary gland involvement. Ultrasound (US) examination was performed with a 15 MHz linear probe (General Electric LOGIQ S8). The parenchymal homogeneity of bilateral parotid and submandibular glands was graded using a score of 0 (normal) to 4 (gross inhomogeneity). Patients were classified into two groups according to the highest US score obtained. The grades 1 and 2 were considered to be normal and grades 3 and 4 to represent pathological SGUS findings. Demographics (age, sex and disease duration), European League Against Rheumatism Sjögren's Syndrome Disease Activity Index (ESSDAI) and laboratorial data (erythrocyte sedimentation rate, autoantibodies, rheumatoid factor, hypergammaglobulinemia, b2-microglobulin and complement levels) were collected and compared between the two SGUS groups. The association between SGUS and these data was explored by multivariable analysis. Statistical significance was defined as p <0.05. Results: The mean age of patients was 57.5±13.3 years and median disease duration was 5.0 [IQR (2.75-11.25)] years. The majority of the study population were women (96%) and 35% (19/54) had pathological SGUS findings. Differences between the group with pathological SGUS versus the group with normal SGUS are depicted in Table I. Multivariate logistic regression revealed that anti-SSB (odds ratio [OR] = 6.6, 95% confidence interval [CI] 1.7 to 25.8, p = 0.006) was independently associated with the presence of pathological features in SGUS. Conclusion: In our study, pathological US findings were associated with higher disease activity and positivity for rheumatoid factor and anti-SSB. Additionally, anti-SSB antibody was strongly and independently associated with pathological US findings in the salivary gland of pSS patients. Further and larger studies are necessary to support these findings and include SGUS as part of the diagnostic criteria for Sjögren's syndrome. [ABSTRACT FROM AUTHOR]

Copyright of Acta Reumatológica Portuguesa is the property of Sociedade Portuguesa de Reumatologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Acta Reumatológica Portuguesa is the property of Sociedade Portuguesa de Reumatologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Acta Reumatológica Portuguesa is the property of Sociedade Portuguesa de Reumatologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: Rheumatoid arthritis (RA) is characterized by synovitis of multiple joints which if not properly treated can progress to joint destruction. When liver damage is present in RA patients, it may be difficult to determine if it is an hepatic manifestation of RA, if there is an associated primary liver disease or whether hepatotoxic liver disease developed during the treatment of RA. Primary biliary cholangitis (PBC) is an autoimmune disease of the liver of unknown origin. It is characterized by inflammation and destruction of intrahepatic bile ducts, resulting in progressive cholestasis and, potentially, liver cirrhosis. About 1.8 - 5.6% of individuals with PBC have RA. Patients with RA are at higher risk of developing PBC compared to the general population. Objective: We report a case in which tocilizumab therapy was effective in the control of RA and PBC. Clinical Case: A 76-year-old man, previously diagnosed with PBC treated with ursodeoxycholic acid (UDCA), was observed in our Rheumatology department with symmetric and additive polyarthritis of small joints of the hands (metacarpophalangeal and proximal interphalangeal joints). Blood sample analysis revealed positive anti-citrullinated protein antibodies (ACPA) antibodies and rheumatoid factor along with increased inflammatory parameters, elevation of gamma glutamyltranspeptidase (5 times the upper limit of normal (ULN)) and alkaline phosphatase (2 times ULN). Plain hand radiographs showed erosions and ultrasound revealed synovitis of several metacarpophalangeal and interphalangeal proximal joints. The diagnosis of RA was established. Due to abnormal cholestasis blood markers it was decided to start only prednisolone 10mg/day, with clinical and analytical improvement. However, a relapse was observed with the reduction of corticoid dose. Introduction of conventional synthetic DMARDs was contraindicated due to the hepatic abnormalities. At this point, the rheumatologist and gastroenterologist's opinion was to start biological therapy in monotherapy and tocilizumab was chosen. With this treatment, the patient experienced significant clinical and analytical improvement, without new episodes of arthritis and with normalization of both inflammatory and hepatic cholestasis markers. Thus, prednisolone was progressively tapered and the patient maintained sustained remission of RA and PBC with tocilizumab and UDCA. Discussion: In RA, tocilizumab monotherapy was shown to be superior to methotrexate monotherapy. This was not observed with TNF-α inhibitors.5 Furthermore, autoimmune hepatitis incidence is increased with anti-TNF-α therapy.6 In PBC there is a deregulation of the T lymphocytes, with lymphoid infiltration in the portal ducts. In addition, local inflammation leads to the activation of mononuclear cells and production of IL-6 and others cytokines.7 This increase of IL-6 shown in PBC may justify tocilizumab good response in this clinical case. This case report, along with published literature 8 data suggests that tocilizumab may be effective and safe in the treatment of RA in patients with PBC. Inhibition of IL-6 seem to lead to normalization of inflammatory activity, which may also be effective in PBC treatment, but further studies will be necessary to confirm this hypothesis. [ABSTRACT FROM AUTHOR]

Copyright of Acta Reumatológica Portuguesa is the property of Sociedade Portuguesa de Reumatologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Acta Reumatológica Portuguesa is the property of Sociedade Portuguesa de Reumatologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: The association between cardiovascular (CV) risk and chronic systemic inflammatory diseases has been an issue of debate. There is compelling evidence of increased CV morbidity in conditions such rheumatoid arthritis (RA) and systemic lupus erythematous (SLE) (1). Primary Sjögren's syndrome (pSS) is a chronic immune-mediated disease characterized by glandular and systemic manifestations, sharing clinical and immunological similarities with RA and SLE. However, in pSS patients the weight of cardiovascular disease attributed to traditional CV risk factors remains unclear. Objectives: To determine the prevalence of traditio nal CV risk factors and long-term CV events based on the risk prediction tool of the Framingham risk score (FRS) in pSS patients. Methods: The study included patients diagnosed with pSS, fulfilling both the 2016 ACR/EULAR and 2002 AECG criteria for the disease, followed-up at our Rheumatology department and 49 age and sexmatched controls. Inclusion criteria were age 30 to 74 and no history of CV events in order to calculate the FRS. In total, 46 out of 54 patients were eligible for the study. Data on the prevalence of traditional CV risk factors (diabetes, arterial hypertension and smoking), systolic blood pressure (SBP) values, total and high-density lipoprotein (HDL) cholesterol levels were collected and compared between groups. The 10-year risk for CV events according to FRS was calculated and means of patients and controls were compared. Parametric and nonparametric tests were used and the level of significance was defined as p<0.05. Results: The mean age of pSS patients and healthy individuals was 58.0±11.6 and 54.1±13.6 years, respectively. The prevalence of arterial hypertension was hi - gher in pSS patients than controls (52.2% versus 24.5%, p=0.005). The prevalence of diabetes and smoking did not differ significantly between the two groups (p=0.674 and p=0.949, respectively). The SBP values, total and HDL cholesterol levels were also similar between pSS patients and healthy subjects (p=0.063, p=0.413 and p=0.217, respectively). Mean 10-years risk for CV events assessed by FRS was 11.8±8.3 for pSS patients and 7.8±8.4 for matched controls, with statistically significant difference (p=0.013). Conclusion: In our study, pSS patients had a higher prevalence of arterial hypertension, which is in agreement with the M. Juarez et al (1) study. Although there were no significant differences in the other traditional CV risk factors, the results showed an increased 10-year risk for major CV events based on FRS assessment in pSS patients in comparison to age and sex-matched controls. [ABSTRACT FROM AUTHOR]

Background: Remission/ low disease activity (LDA) are the main treatment goals in rheumatoid arthritis (RA) patients. Two tools showing the ability to predict golimumab treatment outcomes in patients with RA were published., Objectives: To estimate the real-world accuracy of two quantitative tools created to predict RA remission and low disease activity., Methods: Multicenter, observational study, using data from the Rheumatic Diseases Portuguese Register (Reuma.pt), including biologic naïve RA patients who started an anti-TNF as first-line biologic and with at least 6 months of follow-up. The accuracy of two matrices tools was assessed by likelihood-ratios (LR), sensitivity (SN), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) and area under the ROC curve (AUC)., Results: 674 RA patients under first-line anti-TNF (266 etanercept, 186 infliximab, 131 adalimumab, 85 golimumab, 6 certolizumab pegol) were included. The median (IQR) age was 53.4 (44.7-61.1) years and the median disease duration was 7.7 (3.7-14.6) years. The majority were female (72%). Most patients were RF and/or ACPA positive (75.5%) and had erosive disease (54.9%); 58.6% had comorbidities. At 6-months, 157 (23.3%) patients achieved remission (DAS28 ESR < 2.6) and 269 (39.9%) LDA (DAS28 ESR ≤ 3.2). Area under the curve for remission in this real-world sample was 0.756 [IC 95% (0.713-0.799)] and for LDA was 0.724 [IC 95% (0.686 -0.763)]. The highest LR (8.23) for remission state was obtained at a cut-off ≥ 67%, with high specificity (SP) (99.6%) but low sensitivity (SN) (3.2%). A better balance of SN and SP (65.6% and 73.9%, respectively) was observed for a cut-off >30%, with a LR of 2.51, PPV of 43.3% and NPV of 87.6%., Conclusion: In this population, the accuracy of the prediction tool was good for remission and LDA. Our results corroborate the idea that these matrix tools could be helpful to select patients for anti-TNF therapy.

Objectives: Characterization of sociodemographic and clinical aspects of patients admitted to the Orthopedic Department (OD) after observation in the Emergency Room (ER) with the diagnosis of septic arthritis (SA)., Material and Methods: A retrospective, monocentric, cross-sectional study was conducted. Sociodemographic and clinical data on patients admitted to the OD with suspected SA between April 2014 and September 2019 were collected., Results: One-hundred and ten patients were included. In the overall sample, most patients were male (n=61; 55.5%) with a median age of 70 (IQR=20) years old. Thirty-six patients (32.7%) had a previous history of hyperuricemia or gout, or had this diagnosis established at the time of their hospital admission. Monoarthritis was the most common form of presentation (n=106; 96.4%), with the knee being the most frequently involved joint (n=60; 54.5%). S. aureus was the most representative microorganism in synovial fluid (SF) cultures (n=33; 30.6%). SF cultures did not allow the identification of a causative microorganism in 53 cases submitted to arthrotomy (50.5%). Serum C-reactive protein (CRP) was a predictive factor for microorganism identification in SF cultures, with values ≥ 17.6 mg/dl presenting a sensibility and specificity of 60.8% and 77.4%, respectively [CI 95% (0.52 - 0.80)]. Patients with a diagnosis of hyperuricemia or gout presented a higher risk for a negative SF culture result (OR = 4.7 [CI 95% =1.9 - 11.5])., Conclusions: Elderly subjects with multiple comorbidities, namely cardiovascular risk factors, seem more prone to SA. Serum CRP appears to be a predictive factor for the identification of a causative microorganism. The higher risk of a negative SF culture in patients with hyperuricemia or gout should alert us for the possibility of misdiagnosis of SA in patients with an acute gout attack.

Osteoarthritis (OA) is frequently regarded by patients and health care providers as a normal consequence of ageing and a minor condition. In contrast, rheumatoid arthritis (RA) is a pathological condition that usually requires prolonged treatment and regular Rheumatology follow-up. Pain and physical limitations are hallmarks of both conditions and some previous studies suggest that OA and RA may have a similar burden for both groups of patients although those works usually do not take into account the inflammatory activity of RA. With this work, the authors compare levels of pain, physical disability and health-related quality of life in patients with primary hand osteoarthritis (hOA) and with RA - active disease (aRA) or in remission (rRA). The results show that hOA may have similar or even higher burden of pain than RA even with clinically relevant inflammatory activity in hand joints. Rather than suggesting that OA could be as severe as RA (or more or less severe), this brief study highlights OA as a cause of severe pain, which should lead us to try to achieve better symptom control for these patients and encourage rheumatologists to endeavor efforts to perform more studies in the field of OA.

Objective: To evaluate and describe the strategies of Portuguese rheumatologists and paediatricians, regarding either the maintenance or the withdrawal of classic and biologic disease-modifying anti-rheumatic drugs (cDMARDs and bDMARDs, respectively), when patients with Juvenile Idiopathic Arthritis (JIA) achieved clinical inactive disease (CID)., Methods: We performed a 30-question questionnaire, which was sent to all the 35 clinicians enrolled in the Portuguese group of paediatric rheumatology., Results: Twenty-three complete responses were obtained. The factors with the greatest impact on the decision to withdraw cDMARDs were: the duration of the CID, the therapy-induced toxicity, the presence of erosive disease and joint damage, the subtype of JIA, the time to reach inactive disease and the low adherence to therapy. These factors were classified as "very important" in this decision by more than 50% of the clinicians. The same factors, except for low adherence, had the greatest impact, when considering the withdrawal of bDMARDs. Withdrawal was more likely in patients with persistent oligoarticular JIA and less likely in rheumatoid factor positive polyarticular JIA. Sulfasalazine was more susceptible to be discontinued than methotrexate. Contrariwise, there were no differences concerning bDMARDs. Most participants reported that they started the drug withdrawal only after 12 months of sustained remission, by progressively tapering the dose of the cDMARD and spacing the intake of the bDMARD. Also, they reported that the decision to suspend the DMARD was based on imaging methods, preferably ultrasound, and in patient-reported outcomes. For patients on combination therapy, bDMARDs are reported to be the first to be withdrawn., Conclusions: Literature is scarce on this matter and there are no well-defined guidelines on how to withdrawal cDMARDs or bDMARDs on JIA. Notwithstanding, most Portuguese physicians were in agreement on the factors that needed to be taken into account with respect to the withdraw decision.

Objectives: To evaluate belimumab effectiveness and safety in real-life Portuguese patients with Systemic Lupus Erythematosus (SLE)., Materials and Methods: Multicenter cohort study including all SLE patients treated with belimumab in seven Portuguese rheumatology centers. Demographic, clinical and serological data were collected at baseline, 6, 12 and 24 months of treatment with belimumab. To evaluate effectiveness we used SLE Responder Index (SRI) rates and changes in SELENA-SLEDAI. Safety was evaluated by the number of adverse events., Results: Thirty-eight patients were included: 37 (97.4%) female, with a mean age of 46.2±13.9 years. Mean SELENA-SLEDAI was 8.2±3.9, 78.8% had elevated anti-double-stranded DNA (anti-dsDNA) antibodies and 72.7% had complement consumption at baseline. Multiorgan involvement was the leading cause for the use of belimumab. SRI response was achieved in 51.9%, 60% and 91.7% at 6, 12 and 24 months of belimumab treatment, respectively. LUNDEX adjusted SRI response rates were 45.4%, 45.0% and 45.8% at 6, 12 and 24 months of belimumab, respectively. Mean SELENA-SLEDAI, anti-dsDNA antibodies and daily prednisolone dosage decreased significantly from baseline to 6, 12 and 24 months and C3 levels increased significantly at 12 months of belimumab treatment. Five patients presented adverse events (infections in three cases) and eleven patients discontinued belimumab (four due to inefficacy, three due to adverse events and four were lost to follow-up)., Conclusions: Our study confirmed, in real-life Portuguese patients with active SLE, the effectiveness of belimumab in reduction of disease activity, immunological response and steroid-sparing, with a good safety profile.

Introduction: Erasmus syndrome (ErS) is a rare entity in which Systemic Sclerosis (SSc) develops following exposure to silica, with or without associated silicosis. The objectives of this study were: 1) to evaluate the prevalence of ErS in our SSc cohort; 2) to characterize the cases; 3) to evaluate the clinical and laboratory characteristics of SSc in patients with (Ers) or without silica exposure., Methods: Cross-sectional and analytical study. Sociodemographic, clinical and laboratory data were collected from all patients with SSc diagnosed in our department according to ACR / EULAR criteria. Data on professional activity and possible exposure to silica were obtained by phone interview., Results: Among 48 patients with SSc, the prevalence of ErS was 16.7% (8/48). All cases identified were male, corresponding to 72.7% of men with SSc followed at our department. There was a statistically significant association between ErS and male gender (p.

Objectives: After consultations, the physician's perceptions differ from the patient's perceptions concerning illness level, cause, and nature of the problem and content of the consultation. Agreement on problems requiring follow-up was associated with a better outcome. The primary aim of this study was to build and validate an instrument that could assess physician-patient agreement in the rheumatology consultation. The secondary objective was to assess agreement association with patient's clinical and sociodemographic data., Materials and Methods: A ten-item questionnaire - "Consultation Assessment Instrument" (CAI) - was developed for this study to assess the physician-patient agreement. Ten physicians and 102 patients diagnosed with an inflammatory joint disease under biological therapy were included. The items were evaluated and the index of proportional agreement for the dichotomized answers "agree" (Ppos) and "disagree" (Pneg) was calculated., Results: Consultation satisfaction was the item with the highest agreement. On the opposite end, the item about the explanation of treatment importance was the item with the lowest agreement between patient and physician. Except for one item, the high level of agreement between patient and physician was due to a higher Ppos. Index of proportional agreement was high for 9 of the 10 items (0.816≤ Iv ≤0.990). Patients with lower disease activity scores had a more positive experience. A good internal consistency was obtained for both patient's and physician's questionnaire (α = 0.88 and α = 0.80, respectively)., Conclusions: Both patient and physician showed a positive experience towards Rheumatology consultation. Physician-patient agreement was high in the majority of the consultation aspects (mean Iv = 0,93). A good internal consistency was obtained for both patient's and physician's questionnaire. CAI could be useful as a mental checklist in daily practice or as an educational tool for training consultation skills.

Introduction: Shoulder pain is a common cause of consultation in Primary Health Care, and may correspond to up to 30% of the reasons for consultation. Pathology of the rotator cuff is the most common cause of pain. Ultrasound is a valuable diagnostic tool in assessing shoulder disorders; it can be as effective as magnetic resonance imaging., Objective: To determine the predictive factors of response to treatment and ultrasound findings in shoulder pain., Methods: We performed an analysis of the patients' cases sent to the rheumatology consultation with shoulder pain, every patient had an echography shoulder evaluation, and the rheumatologist decided treatment based on the guidelines for the treatment of shoulder tendinopathies. The use of nonsteroidal anti-inflammatory drug (NSAIDs) and muscle relaxant medications as well as the following techniques: corticosteroids local injection, barbotage, capsular distension and physiotherapy programs were some of the variables assessed. Posteriorly, the patients were clinically assessed in a follow-up visit., Results: A total of 119 patients were evaluated. There was a statistically significant relationship between the time from the beginning of the symptomatology and treatment response. Diabetes mellitus, arterial hypertension and dyslipidaemia were statistically significantly associated with some rotator cuff lesions and distention of the subscapular bursa. Age is the main predictor of rotator cuff ultrasound findings., Conclusion: In patients with shoulder pain, early intervention positively influences the response to treatment. Thus, it is important that these patients are evaluated more promptly. Some comorbidities seem to be associated with a higher risk of specific rotator cuff lesions. No relationship was found between response to treatment and age, sex, occupation, previous treatments or type of therapy selected. The associations found in this study seem to have clinical implications. Prevention of rotator cuff disease is a matter of major relevance as well as early institution of treatment.

Objectives: Evaluation and characterization of hand function in patients with rheumatoid (RA) arthritis and, secondarily, identification of the use of adaptive equipments., Material and Methods: Firstly, a written informed consent was obtained and then an anonymous questionnaire was filled by RA outpatients after observation at the rheumatology consultation with no other musculoskeletal or neuromuscular disorders that would determine major functional impairment of hand function. Sociodemographic and clinical variables were collected and the Cochin Hand Functional Scale (CHFS) was applied. Classical deformities of hand and/or wrist were observed and recorded by the attending physician., Results: A total of 79 patients were enrolled. In the overall sample, most patients were female A sample of 79 patients, mostly female (69.60%), with a mean age of 59.72 ± 11.77 years and with a mean diagnosis duration of 11.72 ± 8.29 years. The majority (73.40%) had at least one hand or wrist deformity, the most frequent being atrophy of the interosseous muscles followed by ulnar deviation of the metacarpophalangeal joints and piano key deformity of the wrist. The mean CHFS score was 17.94 ± 18.26 points with a minimum and maximum value recorded of 0 and 80 points, respectively. The presence of hand deformities, Health Assessment Questionnaire score (HAQ), hand pain and diagnosis duration were correlated with the CHFS score. Six patients had assistive devices and only in one case it was used to overcome hand's functional impairment., Conclusions: Most patients presented at least one classic RA deformity after a mean diagnosis duration of approximately 12 years and under pharmacological treatment. Despite this, most patients scored significantly below CHFS maximum score, but only 18 reported no difficulty in any of the tasks mentioned in the scale. The fact that only a minority of these patients had assistive devices should alerts us to the need for a more thorough functional assessment and identification of needs among RA patients.

Introduction: Concerns about the side effects and interactions of biologic drugs with reproduction and pregnancy have been always an issue between experts. The safety of these therapies during conception and/or pregnancy is not fully understood. The aim of this study was to assess the exposure to biologic drugs before and/or during conception/pregnancy and the risk of adverse pregnancy outcomes in women with rheumatic diseases., Methods: We conducted a cohort study of pregnancies reported in women with immune-mediated rheumatic diseases registered at the Rheumatic Diseases Portuguese Registry (Reuma.pt) and exposed to biologic drugs. Data concerning fetal and maternal outcomes (live birth, spontaneous abortion, neonatal and intrauterine death, intrauterine growth restriction, premature delivery, congenital malformations, neonatal lupus, voluntary or medical interruption of pregnancy, disease flares and need for treatment with other drugs) was extracted., Results: In total, 69 pregnancies from 56 females were analysed, the majority with the diagnosis of spondyloarthritis or rheumatoid arthritis. In almost half of the cases (n=32, 46.4%) the biologic was stopped for pregnancy planning, in 31 cases (44.9%) it was stopped when pregnancy was diagnosed and in 6 pregnancies (8.7%) biologic therapy was maintained, at least until the 2nd trimester. There were 76.8% of live births and 22% of spontaneous abortions. Congenital anomalies were reported in 2 newborns., Conclusions: In half cases, it was decided to stop biologic therapy in the family planning period. Using biologic disease-modifying anti-rheumatic drugs before and/or during pregnancy doesn't seem to affect the overall maternal and fetal outcomes. Pregnancy planning and treatment options should be discussed and a shared decision should be established between physician and patient.

The study was conducted in order to investigate adherence in patients with Rheumatoid arthritis (RA), correlating it with other variables such as affect and self-esteem. Seventy-eight patients with RA between 20 and 81 years of age were evaluated. Patients were assessed for Medical Outcomes Study (MOS) Measures of Patient Adherence, Rosenberg self-esteem scale and Short Portuguese version of the Positive and Negative Affect Schedule (PANAS). Pearson's correlation coefficient was used to assess the correlation between the therapeutic compliance and age, disease activity, disability, GPA, self-esteem, affect and inflammatory parameters. An independent T-test was used to evaluate differences in adherence within gender. The one-way analysis of variance (ANOVA) was used to determine associations between adherence and marital status, education level and employment status. A linear regression model was adjusted with stepwise data entry to determine predictors of therapeutic compliance. Patients had a mean age of 57 years and disease duration of 12.8 years. We observed higher levels of adherence in patients with higher self-esteem (r= 0.343, p&lt0.05) and positive affect (r= 0.345, p&lt0.01). The adjusted linear regression model allowed the identification of positive affect as a RA patient's adherence predictor (R = 0.347, p&lt0.05). In our study, high levels of self-reported adherence in RA patients were found. Positive affect seems to be an important determinant of therapeutic adherence in RA patients. These results suggest a relevant role of psychosocial aspects in therapeutic compliance and outcome, which should alert physicians to the need of an holistic approach of the patient.

Objectives: To compare the effectiveness of a 2nd TNF inhibitor (TNFi), Tocilizumab (TCZ) and Rituximab (RTX), measured by drug retention and by response rates, in RA patients after discontinuing a first-line TNFi and to clarify the reasons and predictors for discontinuation of a second-line biologic., Material and Methods: Non-interventional prospective study of RA patients exposed to a 2nd TNFi, TCZ or RTX after previous TNFi discontinuation using real-world data from Reuma.pt database. Drug retention was estimated using Kaplan-Meier analysis and Cox models. Crude and LUNDEX adjusted response rates were evaluated at 6 months, 1 and 2 years and reasons for discontinuation were compared according to biologic class., Results: In total, 643 patients were included, 88.8% females, with a mean age of 59.4±12.8 years. Of those, 390 (60.7%) initiated a 2nd TNFi, 147 (22.9%) TCZ and 106 (16.5%) RTX. Drug retention was significantly greater among patients who initiated TCZ (76.4±4.3 months) or RTX (80.8±4.8 months), compared with those who initiated a 2nd TNFi (52.7±2.6 months) (log rank test, p < 0.001). In the adjusted Cox model, hazards of discontinuation were significantly lower for TCZ (HR 0.39, 95% CI 0.23-0.64, p < 0.001) and RTX (HR 0.42, 95% CI 0.25-0.72, p=0.001). Smokers had a significantly higher risk for discontinuation (HR 2.43, 95%CI 1.50-3.95, p < 0.001) as well as patients with higher HAQ at baseline (HR 1.51, 95%CI 1.14-2.00, p=0.004). The proportion of patients in remission or low disease activity according to Clinical Disease Activity Index (CDAI) at 6 months, 1 and 2 years was, respectively, 46.5%/50.0%/61.2% for TNFi, 52.9%/53.6%/ 69.2% for TCZ and 37.7%/48.0%/50.0% for RTX. After LUNDEX adjustment, response rates were, respectively, 33.0%/31.0%/31.8% for 2nd TNFi, 42.8%/41.8%/53.3% for TCZ and 32.0%/39.4%/39.0% for RTX. The main reasons for discontinuation were inefficacy for 2nd TNFi and RTX and adverse events for TCZ (p < 0.001)., Conclusions: Our findings showed a significantly higher drug retention for TCZ and RTX, compared with 2nd TNFi, and similar persistence among TCZ and RTX, in patients who discontinued a first-line TNFi. These data corroborate the notion that switching to a biologic with a different mode of action is more effective than to a second TNFi.