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The precise anatomical location of pathology associated with inflammatory back pain (IBP) in early spondyloarthropathy (SpA) remains unclear.To use MRI to study the sacroiliac joint (SIJ) and lumbar spine (LS) and explore the relationship between sites and extent of inflammation and HLA-B27 status over 12 months.54 patients with IBP; median duration 24 weeks (54% HLA-B27 positive; median Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) 5.65) and 22 control subjects (11 with mechanical back pain; 11 volunteers) were recruited and 63% (n = 34) were reassessed at 1 year. Fat saturation and T1-weighted MRI was performed with images being scored for active bone marrow oedema (BMO) lesions representative of inflammation.At baseline 46/54 (85%) patients had BMO (SIJs and LS) compared with 40% in the control group. The majority of affected patients had inflammation at the SIJ level (96% (n = 44); 23.5% (n = 12) LS) and 28.3% (n = 13) at both sites simultaneously. The SIJ activity score confirmed more severe inflammation (BMO grade 2 or 3: 52.2%) in the IBP group (controls = BMO grade 1: 100%; p0.001). HLA-B27 was associated with both the severity (p = 0.009) and number of baseline SIJ lesions (p = 0.045) and with persistence (SIJ or LS) at 1 year (p = 0.02). 90% of reattenders fulfilled European Spondyloarthropathy Study Group criteria; 73.5% showed MRI inflammation despite clinical improvement (median BASDAI 5.65 to 3.05; p0.009).LS and SIJ involvement may occur simultaneously in very early SpA and may be differentiated from non-inflammatory back pain by the severity of MRI lesions. HLA-B27 is associated with both the severity of osteitis and its persistence.

(1) To examine the change in regional bone mineral density (BMD), including the hands, and assess its role as a predictor of outcome in patients presenting with an early undifferentiated inflammatory arthritis; (2) to examine for associations with the changes in hand BMD.74 patients with undifferentiated hand arthritis of less than 12 months' duration were examined at baseline and then at three, six, and 12 months follow up, including BMD measurement of the femoral neck, spine (L2-4), and the whole hands using dual energy absorptiometry (DXA).During the study, 13 patients were diagnosed as having rheumatoid arthritis, 19 as having inflammatory non-rheumatoid joint disorders, and 42 as having non-inflammatory joint disorders. At the femoral neck and lumbar spine no significant bone loss was seen in any of the three subgroups. At the 12 months follow up the mean (95% confidence interval) hand BMD loss in the patients with rheumatoid arthritis was -4.27% (-1.41 to -7.13); in the inflammatory non-rheumatoid group, -0.49% (-1.33 to +0.35); and in the non-inflammatory joint disorder group, -0.87% (-1.51 to -0.23). In a multivariate linear regression model (including age, rheumatoid factor, mean C reactive protein, mean HAQ score, and cumulative glucocorticoid dose), only mean C reactive protein (p0.001) and rheumatoid factor (p = 0.04) were independently associated with change in hand BMD during follow up.Hand DXA provides a very sensitive tool for measuring bone loss in early rheumatoid arthritis and may be useful in identifying patients at high risk of developing progressive disease. Further studies are needed to evaluate the role of hand bone loss as a prognostic factor and outcome measure in rheumatoid arthritis.

Hand pain with stiffness is a common clinical presentation to early arthritis clinics, with outcome varying from resolution to the development of rheumatoid arthritis.To assess the response and predictors of response to intramuscular methylprednisolone (MP) and hydroxychloroquine (HCQ) using a standardised treatment protocol.Patients with inflammatory hand pain (IHP), defined as predominantly hand pain and morning stiffness of at least 30 min duration, received a standardised assessment prior to receiving intramuscular MP. Response (primary outcome) at 4 weeks was a 50% improvement in symptoms as perceived by the patient; responders who relapsed received repeat intramuscular MP and HCQ.102 patients were recruited, of which 21% were rheumatoid factor (RF) positive, 23% had clinical synovitis, 25% had raised C-reactive protein level and 55% had ultrasound-detected synovitis. 73% responded, with associated significant reductions in morning stiffness, Health Assessment Questionnaire, painful and tender joint counts, and visual analogue scores (por = 0.006 for all). Ultrasound-detected synovitis (p0.001) and RF (p = 0.04), but not clinical synovitis (p = 0.74), were significantly associated with response to intramuscular MP. 86% who remained on HCQ long term reported a benefit.Patients with IHP have significant improvement in symptoms and function following intramuscular MP. Further placebo-controlled trials are required to assess the role of intramuscular MP and ultrasonography in managing this patient group.

To examine the role of hand dual-energy x ray absorptiometry (DEXA) compared with radiography in the assessment of bone involvement in patients with early rheumatoid arthritis (RA) who have active disease.The study population (n = 79) had RA of12 months' duration and were selected for poor prognostic features. Clinical data and bone mineral density (BMD) data were collected at baseline, 24 and 48 weeks. Hand radiographs were performed at baseline and 48 weeks. Bone damage analyses were performed for the group and individuals using the smallest detectable change (SDC) method.At baseline, mean disease duration was 8.5 months, erythrocyte sedimentation rate was 34.3 mm/hour, C-reactive protein was 40.2 mg/l, Health Assessment Questionnaire score was 1.35 and 81% of patients were positive for rheumatoid factor. Mean (95% CI) hand BMD loss was 2.5% (-3.5 to -1.5) at 24 weeks and 2.6% (-3.8 to -1.5) at 48 weeks. Individual hand bone loss exceeding the SDC was seen in 46.8% at 24 weeks and in 58.2% at 48 weeks. In the subgroup of 58 patients who had undergone radiography, radiographic joint damage score evaluated by the Sharp-van der Heijde method increased from 4.8 to 10.6 (p = 0.001). Individual hand bone loss in this subgroup exceeding the SDC was seen in 50.0% at 24 weeks and in 56.9% at 48 weeks, whereas at 48 weeks only 22.4% had deteriorated in modified Sharp score.The study results indicate that hand DEXA is a more sensitive tool than radiology (radiographic joint-damage scores), for measuring disease-related bone damage in early RA.

Background Oligoarthritis is as an inflammatory arthritis affecting ≤4 joints. It represents either an early clinical presentation or a unique disease phenotype within the group of the SpA. Oligoarthritis typically affects young people causing high morbidity and has a variable. We have previously reported on the effect of early intervention with intra-articular corticosteroids and sulfasalazine (SSZ) in a cohort of patients presenting with an oligoarthritis of recent onset with 80% of patients achieving clinical remission after 52 weeks. We now report on the long-term outcome of this cohort after 10 years. Objectives To report the rate of disease persistence/clinical remission in the long-term follow up of the Leeds cohort of early oligoarthritis. Methods Cross-sectional follow up of patients who participated in two previous interventional studies [1, 2]. Subjects were invited to either attend for a single study visit or a telephone consult. Presence/absence of any musculoskeletal symptoms and current diagnosis was recorded. Blood tests for inflammatory markers and radiographs of SIJs or any relevant joints were performed only if clinically indicated to establish a diagnosis if persistent clinical symptoms. Results The initial cohort comprised of a total of 117 patients, of whom 5 were deceased. An invitation letter was sent out to 112 patients (95.7%). Follow up data are available from a total of 74 patients (63.3%) [mean (SD) disease duration at presentation 13.8 (1.8) months; with a disease duration of 13 (3) years at follow up] of whom 22 (29.8%) attended for a follow up visit; 28 (37.8%) were assessed via telephone consult and 24 (32.4%) had data extracted from the clinical notes. Analysis of the attenders show that 47 patients (63.5%) had had persistent arthritis since the end of the previous studies (19.5% were RF positive; 33.3% antiCCP positive and 32.4% HLA B27 positive). The majority (74%) had received joint steroid injections ± SSZ as previous study protocols. Only 17% had a monoarticular presentation. The majority of patients (83%) had an oligoarticular pattern at disease presentation which was maintained over time in 68%. Fifteen percent (15%) had developed mixed phenotype with axial and peripheral joint involvement. 36.5% of patients (4% and 17.4% RF and HLA-B27 positive respectively) had remained asymptomatic in this time with no hospital follow up. The majority of these (57.7%) had an oligoarthritic pattern at presentation (42.3% monoarthritis), 65.4% had received intra-articular steroids in the previous studies. Conclusions Ten year follow up of an early oligoarthritis cohort shows that over a third of patients attending for review are in drug free clinical remission. The majority had received joint steroid injections ± SSZ early on in their disease onset suggesting that early intervention may lead to clinical remission. These results can throw important insights into the pathogenesis of this condition and provide useful guidance for clinicians managing these patients. References Green, M., et al. Arthritis & Rheumatism, 2001. 44(5): p. 1177-1183. Marzo-Ortega, H., et al. Arthritis & Rheumatism, 2007. 57 (1): p. 154-160. Disclosure of Interest None Declared

Background Early intensive treatment with infliximab (IFX), high dose IV steroids and treating to target have been shown to be effective for remission induction in pts with early RA. Objectives To compare MTX+IFX vs. MTX+high dose IV steroid as induction therapy on radiographic progression in pts with DMARD naive RA. Methods A 78 wk RCT of pts with early (3-12 months symptoms),DMARD naive RA (1987 ACR criteria, DAS>2.4). Pts were randomised to 1of 2 grps:IFX or IVsteroid. Treatment was blinded to wk 26 then guided using a treat to target approach. Both grps received MTX 10mg wkly increasing to 20mg by wk 6. The IFX grp received: IFX 3mg/kg (wks 0,2,6,14,22)+dose adjustment from wk 26 according to DAS44. The IVsteroid grp received: IV methylprednisolone (MP) 250mg at wk 0, placebo infusions at wks 2,6,14,22 & from wk 26 treatment escalation as follows if DAS >2.4: add SSZ+HCQ, then stop SSZ+HCQ & add LEF, then 1 of the following: MTXs/c+LEF or MTX+ciclosporin or MTX+LEF+prednisolone 5-7.5mg dly.IM MP 120mg was administered if DAS >2.4 at wks 6,14,22,38,50 & 62 for both grps. Other biologics were allowed from wk 26 per NICE guidelines. Radiographs of hands & feet done at 0,26,52 & 78 wks were scored using the modified Sharp-van der Heijde (vdH-S) method by 2 independent radiologists blinded to treatment grp;mean of the readers’ scores was taken. Smallest detectable change was calculated to be 2 units. Results 112 pts were randomised to MTX+IFX (n=55) or MTX+IVsteroid (n=57). Baseline mean (SD) age IFX 53.7 (13.3) vs. IVsteroid grp 53.1 (12.8); mean (SD) DAS28CRP IFX 4.2 (1.1) vs. IVsteroid 3.6 (1.1). Remission (DAS Baseline median (IQR) joint space narrowing (JSN), erosion (ERO) and total vdH-S scores (TS) in the IFX (n=42) and IVsteroid (n=51) grps were: JSN 2.0 (0.0-7.5) and 1.5 (0.0-7.0), ERO 0.0 (0.0-1.6) and 0.5 (0.0-2.5), TS 3.0 (0.0-9.5) and 2.5 (0.5-9.5) respectively. At wk 52 (primary endpt), the median change in total vdH-S score was 0.0 (0.0-1.1) units in the IFX and 0.0 (0.0-2.0) units in the IVsteroid arm (p=0.157); median changes did not differ at 26 wks [IFX=0.0 (0.0-0.6) IVsteroid=0.0 (0.0-1.0), p=0.295] or 78 wks [IFX=0.0 (0.0-2.6) IVsteroid=0.5 (0.0-2.4), p=0.325]. Similar results were seen for JSN and ERO scores. Proportions of pts with radiographic non-progression (vdH-S Conclusions In this study of DMARD naive pts with moderate to severe RA, initial therapy with IFX+MTX and high dose IV steroid+MTX, together with tight disease control prevented radiographic progression in a significant majority of patients. Disclosure of Interest None Declared

New bone formation with spinal fusion is the hallmark of ankylosing spondylitis (AS) and the related spondyloarthropathies (SpA), although concomitant osteoporosis is also a major problem both in early and established disease and correlates with disease activity.1 We have previously reported the efficacy of etanercept in patients with active and resistant spinal and peripheral SpA.2 Our aim in this study was to investigate whether suppression of inflammation with etanercept prevents bone loss in patients with AS and SpA. Ten patients with active, resistant spinal and peripheral SpA were treated with a six month course of etanercept 25 mg subcutaneously twice weekly, as previously reported.2 Diagnoses in this group were: AS (n=7), Crohn’s spondylitis (n=2), and undifferentiated SpA (n=1). Results were compared with those for a second group of patients with equivalent disease activity, but shorter disease duration treated conventionally (table 1). The diagnoses of the second group were: undifferentiated SpA …