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Conflicts of interest (COIs) in healthcare are increasingly discussed in the literature, yet these relationships continue to influence healthcare. Research has consistently shown that financial COIs shape prescribing practices, medical education and guideline recommendations. In 2009, the Institute of Medicine (IOM, now the National Academy of Medicine) published Conflicts of Interest in Medical Research, Practice, and Education—one of the most comprehensive reviews of empirical research on COIs in medicine. Ten years after publication of theIOM’s report, we review the current state of COIs within medicine. We also provide specific recommendations for enhancing scientific integrity in medical research, practice, education and editorial practices.

Background Joint replacement surgery represents a remarkable mile stone in the care of patients with rheumatoid arthritis (RA), aimed at improving patients9 functional capacity and reducing pain. Prior to current therapeutic strategies, surgical joint intervention was a frequent event. Currently, orthopedic surgery is considered as a surrogate marker of failed medical treatment and joint destruction. Objectives To compare disease burden in RA patients with and without major joint operation (MJO) in the QUEST-RA study. Methods Consecutive unselected patients with RA receiving usual rheumatology care were included in QUEST-RA study between 2005 and 2012 in 107 clinics in 34 countries (16 with low and 18 with high Gross Domestic Product, GDP, cut at 20,000$/person at the year of enrollment). The review included history of MJO: total joint replacement or fusion of hips, knees, shoulders, elbows, ankles, wrists, and the atlantoaxial joint. Clinical data at the cross sectional visit included disease activity based on DAS28(ESR, 3 variables) and patient reported outcomes (PROs) for disease burden (pain, global health, fatigue on 0-10cm VAS and HAQ on 0-3). Mean values of these variables were compared using parametric statistics in patients with or without history of MJO, according to disease duration (5-10 vs. >10 years), adjusted for age and sex, in countries with low vs. high GDP. Results QUEST-RA includes 10,142 patients; joint operation data were available in 9069 patients (81%Female, mean age 55, median disease duration from symptom-onset 12 years, 74% RF+). Proportion of RA patients with a history of MJO was more than two times in high GDP countries [12.9% (663/5158)] compared to low GDP countries [5.8% (227/3911)] despite the latter having higher disease activity and worse PROs. Disease burden was higher in patients with a history of MJO across the groups (Table) except in patients with shorter disease duration 5-10 years in low GDP countries (all comparisons p=ns, data not shown). Conclusions In the real world setting in 2005-2012, history of MJO in patients with RA indicated higher disease burden and severity compared to patients without MJO. Disclosure of Interest None declared

Granulomatosis with polyangitis (GPA) is an antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis that affects small-sized to medium-sized arteries, and usually involves the upper and lower respiratory tract, and kidneys.1 Digital gangrene can be an unusual feature of GPA.1 ,2 Pulmonary involvement can be in the form of multifocal or solitary lung lesions.1 This case describes a patient with ANCA-positive vasculitis, presenting with digital gangrene and cavitary lung lesions, along with a concomitant Mycobacterium avium -intracellulare (MAI) infection, in the absence of renal involvement. A 59-year-old Caucasian woman presented with blackish discolouration of the fingertips on the right hand that started 3 weeks earlier (figure 1). She first noticed pallor, followed by erythema, cyanotic discolouration and, finally, dry gangrenous transformation of the fingertips. She denied any history of sinusitis, nasal discharge, cough, haemoptysis, or …

Background The ACR/EULAR provisional definitions of remission in rheumatoid arthritis (RA), derived from and developed for clinical trials, recommend use of 28-joint count (JC). Limited data from routine clinical practices exists on the impact of extended JC on RA remission assessment. Objectives To study a) misclassification of ACR/EULAR RA remission when using extended JC (42-JC) versus 28-JC b) impact of non-28 joint (i.e. joints excluded from 28-JC) involvement in patients meeting 28-JC remission. Methods 9450 (7896 with complete data) patients in the Quantitative Standard Monitoring of Patients with RA (QUEST-RA) database receiving usual care from rheumatologists in 32 countries were analyzed. ACR/EULAR remission criteria was defined by fulfillment of all of the following: tender JC ≤1, swollen JC ≤1, patient9s global assessment ≤1, and Erythrocyte Sedimentation Rate (ESR) Results 739 (9.4%) patients met the 28-JC ACR/EULAR remission criteria. 663 (8.4%) patients would meet remission criteria if 42-JC was used, giving a misclassification rate of 1%. Among patients in 28-JC ACR/EULAR remission, 97 (13.1%) had ≥1 tender and/or swollen non-28 joint. Patient in remission with non-28 joint involvement were less likely to meet good functional status criteria (HAQ ≤0.5). Several patient reported outcomes and MDGL were statistically significantly worse in these patients (Table). However, the absolute magnitudes of difference were of questionable clinical relevance. There was no difference in sociodemographic, RA characteristics or treatment pattern among the two groups. Conclusions Our data from patients in routine clinical care from several countries provides further support to the suitability of using 28-JC for assessment of RA remission. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5920

Background Subcutaneous nodules (SCN) are easily identifiable extra-articular manifestation of rheumatoid arthritis (RA) with characteristic histopathology. Identifying clinical characteristics associated with SCN may lead to better pathophysiological understanding of RA, and may enhance its utility as clinical marker of RA outcomes. Objectives To assess prevalence and associations of SCN in a large multinational cohort of RA patients. Methods A cross-sectional study of 8549 patients in the Quantitative Standard Monitoring of Patients with RA (QUEST-RA) database who received usual care from rheumatologists in 33 countries was done. Physicians recorded SCN presence. Multivariable logistic regression (MLR) was used to identify association of SCN with demographic and health characteristics [age, gender, race, smoking status, body mass index (BMI), co-morbidity burden by an index derived from 10 co-morbidities], RA characteristics [RA duration, rheumatoid factor (RF) titer (low 100 IU/ml), radiographic erosions, current RA activity by disease activity score 28 (DAS28), functional status by health assessment questionnaire (HAQ)], and RA treatment [corticosteroids, methotrexate, other disease modifying agents (DMARDs), and biologics]. Results 1787 (20.9%) had SCN. The SCN prevalence varied from 5.1% to 30.3% in different countries. The Table shows the patient characteristics independently associated with SCN. Men, white race, and current smoking were more likely to have SCN. RA duration, presence of erosive disease, high titer RF, but not the current RA activity increased likelihood of SCN. Use of methotrexate and biologics were associated with SCN presence. Patients with SCN had higher comorbidity burden, and were more likely to have higher BMI. Conclusions We confirm previously reported patient characteristics associated with SCN (race, gender, smoking, RA duration, erosive disease, RF titer, methotrexate use), and also report several new associations (biologics use, higher comorbidity burden, BMI). Further studies are needed to determine whether there is true biological basis for these associations. References Ann Rheum Dis 2006;65:601 Scand J Rheumatol 2011;40:81 Disclosure of Interest None Declared

Background Smoking increases cardiovascular morbidity in patients with inflammatory rheumatic diseases, and has been associated with poor response to treatment in rheumatoid arthritis. Advice on smoking cessation is strongly recommended in patients with arthritis. Brief advice versus no advice increases the rate of quitting, thus doctors should aim to advise smokers to quit during routine consultations. Objectives To understand the practice of rheumatologists and nurses regarding advice for smoking cessation in patients with arthritis. Methods We sent a survey to the Rheumatology department participants in the multinational QUEST-RA group. The following items were included: a) number of rheumatologists in department, b) number of nurses for patient education, c) number of doctors and nurses who smoke, d) advice for smoking cessation by doctor and nurse, e) specific protocol for advice in the department, f) special clinic for quitting smoking in the hospital or primary care, and g) specific clinic for early arthritis and/or inflammatory diseases in the department. Results Rheumatologists from 44 departments in 25 countries (16 European) completed the survey. The survey involved 395 rheumatologists of whom 25 (6.3%) smokers, and 199 nurses for patient education of whom 44 (22.1%) smokers. Eight departments (18.1%) had a specific protocol for smoking cessation (Table). 255 (64.5%) Rheumatologists reported giving advice to all or almost all smokers with inflammatory diseases. This advice was more frequent by doctors whose department includes an early arthritis clinic (71% vs 51%; p 80%) in 11 of the 35 (31.4%) departments with nurse for patient education. Rheumatologists in 19 of the 20 (95%) hospitals with specific clinic/unit for smoking cessation reported referring patients to these clinics if a patient asks for help or has lung disease or smoking-related comorbidities. Conclusions Advice for smoking cessation within rheumatology departments is not homogeneous. Two thirds of rheumatologists give advice to quit smoking to all or almost all patients with inflammatory diseases. Only 1 in 5 departments have a specific protocol for smoking cessation. Our data highlights the need to improve awareness of importance and better practice implementation of smoking cessation advice for inflammatory rheumatic disease patients. Disclosure of Interest None Declared

Background The Stanford Health Assessment Questionnaire (HAQ, 20 questions for 8 domains, 21 for devices/aids use)[1][1] has been the gold standard functional status assessment questionnaire in rheumatology. HAQ modifications to improve feasibility by questionnaire shortening, or psychometric properties have been proposed. The modified HAQ (MHAQ, 8 items)[2][2], the multidimensional HAQ (MDHAQ, 10 items)[3][3], and the HAQ II (10 items)[4][4] are most widely used modifications. Conversion formulas have been developed to predict HAQ score from each of these shorter versions to allow comparison across different study populations.[5][5] Objectives To compare distribution of HAQ score with MHAQ, MDHAQ and HAQII scores in a multinational cohort of rheumatoid arthritis (RA) patients and assess the ability of conversion formulas to predict mean HAQ score from the shorter versions. Methods A cross-sectional study of 8488 patients in the Quantitative Standard Monitoring of Patients with RA (QUEST-RA) database who received usual care from rheumatologists in 33 countries was done. Patients simultaneously completed HAQ, MHAQ, MDHAQ & HAQII questionnaires (all scored from 0-3). Mean (SD) and median (IQR) were used to compare score distributions. Proportion of patients with no disability (score = 0) and good functional status (score ≤ 0.5) were assessed. For each of the shorter HAQ versions, proportion that differed from HAQ score by > 0.22 (usually considered minimal clinically important difference) was assessed. Means of predicted HAQ derived from the reported shorter and longer conversion formulas (please see Reference # 5) were compared with the actual HAQ mean. Results HAQ, MHAQ, MDHAQ & HAQII scores were available for 8027 (94.6%), 7979 (94%), 7937 (93.5%) & 6926 (81.6%) patients respectively. Compared to mean HAQ, mean scores were higher for MHAQ and MDHAQ and lower for HAQII ([Table][6]). Compared to HAQ, more patients were classified as having no disability (score = 0) with MHAQ and less patients with MDHAQ and HAQII. MHAQ led to score of ≤ 0.5 in most and HAQII in least number of patients. Scores differed from HAQ by > 0.22 in 66.1%, 43.6%, and 42.5% patients for MHAQ, MDHAQ and HAQII respectively. All predicted HAQ mean scores were higher with actual HAQ mean with best results from shorter formula based on MDHAQ and HAQII (difference 0.11, 10.8%). ![Figure][7] Conclusions HAQ and its shorter versions have different distribution and cannot be used interchangeably for individual patients. Though higher, reasonable estimates for group level HAQ mean can be made from MDHAQ and HAQII thus enabling comparison of patients in different studies. References 1. Arthritis Rheum 1980;23:137; 2. Arthritis Rheum 1983;26:1346; 3. J Rheumatol 2005;32:1432; 4. Arthritis Rheum 2004;50:3296; 5. Arthritis Care Res 2010;62:1481 Disclosure of Interest None Declared [1]: #p-7 [2]: #p-8 [3]: #p-9 [4]: #p-10 [5]: #p-11 [6]: #F1 [7]: pending:yes