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Background Primary Sjogren's syndrome (pSS) is an autoimmune disease that leads to salivary and lacrimal gland dysfunction. The adaptive immune response associated with T helper-2 lymphocytes appears to be altered in these patients. Therefore, the objective of this study was to determine the salivary levels of interleukin (IL)-6, IL-5, and IL-4 in patients with pSS when compared to a healthy control (HC) group. The secondary objectives were to study whether ILs levels in pSS patients were associated with salivary flow, patient-reported outcomes (PROMs) for xerostomia and oral health quality of life (Oral Health Impact Profile-14 [OHIP-14]), pSS classification criteria and presence of extraglandular manifestations. Methods A case-control study was conducted in 36 patients with pSS and 35 HCs. Cytokine levels were measured using high-sensitivity multiplex map human immunoassays. Unstimulated and stimulated whole saliva were collected and patients filled out questionnaires. The Mann-Whitney U test, chi-squared test, and Spearman correlation test were used. Results Interleukin-6 was significantly higher in pSS patients than in HCs (P = .0001). IL-6 was significantly higher in pSS patients with a positive salivary gland biopsy (P = .04), whole stimulated saliva hyposalivation (P = .02), and presence of musculoskeletal disorders (P = .03). There was a non-significant positive correlation between IL-6 levels and PROMs for xerostomia (r = .31; P = .06) and OHIP-14 (r = .07; P = .68) in pSS patients. Levels of IL-4 and IL-5 were not detected in both pSS and HCs patients. Conclusions Salivary IL-6 levels are significantly associated with pSS patients, and therefore, it is hypothesized that this biomarker may be useful in the diagnosis and follow-up of this disease.

Background Candidiasis is the most frequent mycotic infection of the oral cavity. The aim of this study was to investigate the presence of clinical oral candidiasis and Candida albicans yeast in a population diagnosed of primary Sjögren’s syndrome (pSS) and to study the possible factors associated with this infection. Material and Methods An observational cross-sectional study was conducted in 61 pSS patients (60 women, 1 man, mean age 57.64±13.52) where patient based information (demographic and medical, tobacco and alcohol consumption history), intraoral parameters (presence of dentures, clinical signs of candidiasis), salivary analytical information (number of Candida albicans as colony-forming units per millilitre (CFU/mL), salivary pH levels, unstimulated whole saliva (UWS) and stimulated whole saliva (SWS) were collected. Results 13.1% of pSS patients presented oral signs of candidiasis. Denture stomatitis and angular cheilitis were the most common lesions. 87.5% of patients with clinical candidiasis presented reduced pH levels and salivary flow in both UWS and SWS. A significant statistical negative correlation was found between CFU/mL of Candida albicans and levels of UWS and SWS. A negative correlation was found between pH levels and CFU/mL, although not statistically significant. Conclusions A reduced salivary flow may predispose pSS patients to Candida albicans overgrowth, which may show with clinical signs. Preventive measures are of great importance to avoid and to treat this condition promptly. Key words:Sjögren’s syndrome, oral candidiasis, oral lesions, Candida albicans, oral yeast, salivary flow rate, hyposalivation.

Background and objectives Influenza vaccine is recommended for patients with autoimmune inflammatory rheumatic diseases who receive biological therapy. To evaluate if biological therapy impairs immunization after seasonal influenza vaccine. Material and methods Patients with inflammatory arthopathies, psoriasis, inflammatory bowel disease or connective tissue diseases who were receiving or were going to initiate biological therapy were included and vaccinated during 2014–2015 influenza season. ELISA was used to measure influenza antigen A and B antibodies, before and after vaccination. Demographic parameters, diagnosis and kind of treatment were recorded and their influence on the final serological status against influenza was studied. Results 253 subjects were analyzed. After vaccination, 77% of participants presented detectable antibodies against antigen A and 50.6% of them had detectable antibodies against antigen B. Final seropositivity rate against antigen B antibodies increased from baseline (50.6% vs 43.5%, p

This study aimed at determining socio-demographic and clinical factors of primary Sjögren syndrome (pSS) associated with osteoporosis (OP) and fragility fracture. SJOGRENSER is a cross-sectional study of patients with pSS, classified according to American European consensus criteria developed in 33 Spanish rheumatology departments. Epidemiological, clinical, serological and treatment data were collected and a descriptive analysis was conducted. Bivariate and multivariate analyses were performed using a binomial logistic regression to study the factors associated with OP and fragility fracture in pSS. 437 patients were included (95% women, with a median age of 58.6 years). 300 women were menopausal (76.4%). Prevalence of OP was 18.5% [in men (N = 21) this measured 19%]. A total of 37 fragility fractures were recorded. In the multivariate analysis, there was an association between OP and age: in the 51-64 age range (menopausal women), the OR measured 9.993 (95% CI 2301-43,399, p = 0.002); In the age 64 years group, OR was 20.610 (4.679-90.774, p 0.001); between OP and disease duration, OR was 1.046 (1.008-1085, p = 0.017); past treatment with corticosteroids, OR 2.548 (1.271-5.105, p = 0.008). Similarly, an association was found between fragility fractures and age: in the 51-64 age group, OR measured 5.068 (1.117-22,995, p = 0.035), age 64 years, OR was 7.674 (1.675-35,151, p 0.009); disease duration, OR 1.049 (CI 1.003-1097, p 0.036) and the ESSDAI index, OR 1.080 (1.029-1134, p = 0.002). Patients with pSS can develop osteoporosis and fragility fractures over the course of the disease. Age, corticosteroids treatment and disease duration were associated with the development of OP. Disease duration and ESSDAI were associated with the development of fractures in patients with pSS.

To evaluate the response to hepatitis B virus (HBV) vaccine in patients on biological therapy. Adults with autoimmune inflammatory diseases on biological therapy such as anti-TNFα, rituximab, tocilizumab, abatacept, or anakinra were included. Hepatitis B surface antibody (anti-HBs) was measured by ELISA before and after vaccination. Seroconversion was considered when an anti-HBs titer 10 mIU/mL was achieved. The effect of treatment on the immunoprotective state was studied. The response was compared with that obtained in patients on synthetic disease modifying anti-rheumatic drugs (DMARDs) and healthy controls. A total of 187 patients on biologicals, 48 on synthetic DMARDs, and 49 on healthy controls were analyzed. More than 80% of patients on biologics responded to the vaccine but required more boosters and second vaccine series. Patients who achieved seroconversion were younger than those who did not (47.10 ± 12.99 vs. 53.18 ± 10.54 years, p = 0.012). Being on etanercept or golimumab was associated with seroconversion, while being on rituximab was not. Seroconversion was achieved in 93.75% of patients on synthetic DMARDs and 97.96% of healthy controls. The seroconversion rate in the biologics group was lower than in the synthetic DMARD group (p = 0.043) and tended to be lower than in the healthy group (p = 0.056). In patients on biological therapy, a high rate of HBV vaccine response can be achieved when a complete vaccination schedule is administered. Vaccination while not on biological agents reduces the requirement for boosters and revaccination. Key points: • Patients on biological therapy can achieve high rates of immune response to HBV vaccine when complete vaccination schedules are administered. • However, to achieve such a high seroconversion rate, more boosters and second vaccination series are required. • This supports the proposal already made to provide HBV vaccination to all patients with an autoimmune inflammatory disease after the diagnosis is made and not when the use of a biological treatment is under consideration.

Background Primary Sjogren’s syndrome (pSS) is characterized by lymphocytic infiltration of the exocrine glands. These patients have a higher risk than the general population of developing non-Hodgkin lymphoma (NHL). This risk also increases with the time of evolution of the disease. pSS is also associated with the development of non-hematological cancer such as thyroid, digestive or gynecological among others. Objectives The aim of the study is to explore the association between the development of neoplasia and demographic, clinical or therapeutic factors in pSS. Methods The SJOGRENSER registry is a multicenter, cross-sectional study of patients with pSS who meet the American-European consensus criteria of 2002, of 33 Spanish rheumatology units. The demographic, clinical, analytical, therapeutic and neoplastic data were collected through review of the clinical records and interviews with the patients. Previously, all the patients signed informed consent and the approval of the local ethic committees was obtained. Descriptive statistics was used for the analysis of the data. The chi-squared test was used to establish the statistical associations and it was considered a p Results Four hundred and thirty-seven patients were included in SJOGREN-SER Registry (female gender 95.19%; median age 58.3 years). We found 30 patients (6.86%) with neoplasia (3 of them with more than one neoplasia): 7 with lymphomas (23.3%) (4 MALT lymphomas, 2 Hodgkin’s lymphomas, 1 immunocytoma), 9 with gynecological neoplasia (30%), 2 with digestive malignancies, 2 with hematological, 2 with endocrine, 6 with malignancies in other locations, 3 with multiple mieloma and 2 patients with Waldenstrom macroglobulinemia. The results of the bivariate analysis are shown in the table. The factors significantly associated with the development of neoplasia were older age, glandular inflammatory involvement, lung involvement and use of rituximab. The age at diagnosis of the disease tended to be higher in the group with neoplasia (50.1 (± 12.9) vs 54.7 (± 11.7), p = 0.059). In the multivariate analysis, positive associations were found for the development of neoplasia in older patients (OR 1.045; CI95% 1.010-1.081), patients with glandular inflammation (OR 3.104; CI95% 1.396-6.906), and use of rituximab (OR 3.745; CI95% 1.386-10.118). Conclusion Thirty (6.86%) patients with pSS from the SJOGRENSER registry developed some neoplasia; the most frequent was gynecological, followed by lymphoproliferative processes. Older age, glandular inflammatory involvement and use of rituximab (presumably indication bias) were associated with the presence of neoplasia. References [1] Brito –Zeron, et al. Characterization and risk estimate of cancer in patients with primary Sjogren syndrome. Journal of hematology & oncology 2017;10:90. [2] Liang Y, et al. Primary Sjogren syndrome and malignance risk: a systematic review and meta-analysis. Ann Rheum Dis 2014;73:1151 Disclosure of Interests Monica Fernandez Castro: None declared, Carlos Sanchez-Piedra: None declared, Jose Luis Andreu: None declared, Jose Rosas Consultant for: Abbvie, Amgen, Bristol, Janssen, Lilly, Merck Sharp & Dohme, Pfizer, UCB Pharma, Speakers bureau: Abbvie, Amgen, Bristol, Janssen, Lilly, Merck Sharp & Dohme, Pfizer, UCB Pharma, Victor Martinez Taboada: None declared, Alejandro Olive: None declared

Background Primary Sjogren’s syndrome (pSS) is a systemic autoimmune disease characterized by lymphocytic infiltration of the exocrine glands. Among the extraglandular manifestations, digestive involvement (DI) is frequent, and may condition the quality of life of these patients. There are few studies that systematically analyze gastrointestinal involvement in pSS. Objectives To describe the prevalence of DI in patients with pSS included in SJOGRENSER Spanish registry and the phenotype of these patients, and to analyze their association with other clinical manifestations, serological markers, activity index and treatments used. Methods Transversal multicenter study that includes all patients of SJOGRENSER registry (patients who meet 2002 pSS classification criteria), a study conducted in 33 units of rheumatology in Spain between 2014-2016, which collected demographic and clinical and serological data (1). Patients were classified according to the presence of DI (that included esophagus, stomach, intestine, liver and pancreas). A descriptive analysis was done, with means and standard deviations, frequencies and proportions. Student t for quantitative variables and Chi2 for qualitative ones were performed to evaluate differences between groups. The association of DI with other variables was analyzed by bivariate and multivariate binomial logistic regression analysis. In the multivariate model all variables with p Results From 437 patients included (95% women, median age of 58 years), 59 (13.5%) had some DI (21 (36%) chronic atrophic gastritis, 12 (20%) esophageal dismotility, 3 (5%) lymphocytic colitis, 23 (39%) other). 54% of patients developed DI at the time of pSS diagnosis or later, and 45% before the diagnosis, with a mean age of 49 years at the onset of pSS symptoms. Patients with DI were older, both at diagnosis, onset of pSS symptoms and inclusion in the cohort, than those without it. There were no differences in the ESSDAI index between both groups. Comparison regarding clinical and serological characteristics is shown in Table 1. Patients with DI had more thyroid involvement and C3 hypocomplementemia. In addition, patients with DI had been treated more frequently with glucocorticoids and immunosuppressants. In the multivariate analysis, DI was significantly associated with older age at diagnosis (OR 1.03 (1.00-1.05); p=.005), more C3 hypocomplementemia (OR 2.40 (1.10-5.26) p=.027) and absence of anti-Ro antibodies (OR 0.33 (0.12-0.87) p=.025). Conclusion In patients with pSS from the SJOGRENSER cohort, the prevalence of digestive involvement is 13.5%. These patients are older at diagnosis, have more C3 hypocomplementemia and negative anti-Ro antibodies. These patients need more frequently glucocorticoids and immunosuppressants, suggesting a more severe disease phenotype. Reference [1] Fernandez Castro M, Reum Clin2016; 12:184-9 Disclosure of Interests Sheila Melchor: None declared, Carlos Sanchez-Piedra: None declared, Monica Fernandez Castro: None declared, Jose Luis Andreu: None declared, Victor Martinez Taboada: None declared, Alejandro Olive: None declared, Jose Rosas Consultant for: Abbvie, Amgen, Bristol, Janssen, Lilly, Merck Sharp & Dohme, Pfizer, UCB Pharma, Speakers bureau: Abbvie, Amgen, Bristol, Janssen, Lilly, Merck Sharp & Dohme, Pfizer, UCB Pharma, Patricia Carreira: None declared

Background: Belimumab is a human IgG1l monoclonal antibody directed against BAFF, a B lymphocyte survival factor. It is indicated as adjuvant treatment in adult patients with active systemic lupus erythematosus (SLE), with positive autoantibodies and with a high degree of activity of the disease despite standard treatment. Objectives: This study aims to describe a sample of patients diagnosed with SLE who received treatment with belimumab in a tertiary hospital. Methods: Retrospective longitudinal unicentric observational study. Clinical records of all patients diagnosed with SLE who had received treatment with belimumab were reviewed. Demographic characteristics, clinical manifestations and reason for belimumab indicaton were collected. Results: The twelve patients included in the sample were women. Median age was 48.5 years (31-70). The most frequent reason for indication of belimumab was uncontrolled arthritis. The average time of treatment with belimumab in the total sample was 27.5 (+/- 26.24) months, with a median of 12 months (4-78). Mean treatment time (cases in which belimumab was discontinued excluded) was 31.25 (+/- 26.98) months with a median of 25 (5-78). The average dose reduction of prednisone after initiation of treatment with belimumab (in patients in which it was considered effective) was 5 mg per day (+/- 5). It should be noted that of the 14 cases, treatment was only discontinued in 4 patients, 2 of which were withdrawn due to ineffectiveness. There were 2 adverse events that required drug withdrawal: neutropenia and urothelial carcinoma. (Table). Conclusion: BLM is a well tolerated drug and effective in clinical practice. Adverse effects leading to drug withdrawal are infrequent. Disclosure of Interests: Carolina Merino Argumanez: None declared, Olga Rusinovich: None declared, Consuelo Ramos Giraldez Speakers bureau: Sanofi, Maria Espinosa: None declared, Hilda Godoy: None declared, Carmen Barbadillo Mateos: None declared, Jose Campos Esteban: None declared, Mercedes Jimenez Palop: None declared, Jesus Sanz: None declared, Luis Fernando Villa Alcazar: None declared, Carlos Isasi Zaragoza : None declared, Monica Fernandez Castro: None declared, Jose Luis Andreu Sanchez: None declared

Objective: To compare the prevalence of the main comorbidities in two large cohorts of patients with Primary Sjogren's Syndrome (pSS) and Systemic Lupus Erythematosus (SLE), with focus on cardiovascular (CV) diseases. Methods: Cross-sectional multicenter study where the prevalence of more relevant comorbidities in two cohorts was compared. Patients under follow-up from the SJOGRENSER (Spanish Rheumatology Society Register of pSS) and RELESSER (Spanish Rheumatology Society Register of SLE) registries, and who fulfilled the 2002-AECG and 1997-ACR classification criteria, respectively, were included. A binomial logistic regression analysis was carried out to explore potential differences, making general adjustments for age, sex and disease duration and specific adjustments for each variable, including CV risk factors and treatments, when it was judged appropriate. Results: A total of 437 pSS patients (95% female) and 2,926 SLE patients (89% female) were included. Mean age: 58.6 (p55-p75: 50.0-69.9) and 45.1 years (36.4-56.3), respectively (p

Background Sjögren’s syndrome (SS) is an autoimmune disease related to two common symptoms: dry mouth and eyes. Although, xerostomia and hyposialia have been frequently reported in these patients, not many studies have evaluated other oral manifestations. The aim of this systematic review was to investigate prevalence rates of oral lesions (OL) in SS patients and to compare it to a control group (CG), when available. Material and Methods An exhaustive search of the published literature of the Pubmed, Scopus, Web of Science and the Cochrane Library databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) for relevant studies that met our eligibility criteria (up to September 1st 2017). Results Seventeen cross-sectional studies and one cohort study were finally included. The results showed that SS patients presented more OL compared to non-SS patients. The most frequent types of OL registered in primary and secondary SS were angular cheilitis, atrophic glossitis, recurrent oral ulcerations and grooves or fissurations of the tongue, also when compared to a CG. Conclusions OL are common and more frequent in SS patients when compared to a CG. This may be a consequence of low levels of saliva. More studies where these OL and all the possible cofounding factors are taken into account are needed. Key words:Sjögren’s syndrome, oral lesions, oral diseases, oral manifestations, oral disorders, systematic review.

To identify risk and predictors of lymphoma or lymphoproliferative disease in patients with primary Sjögren syndrome. Articles were identified through a comprehensive search strategy in Medline, Embase and Cochrane CENTRAL. Studies had to investigate primary Sjögren syndrome patients, 18 years of age or older, with the goal of examining potential clinical, immunological and hematological risk factors for lymphoma or lymphoproliferative disease. The quality of the studies was graded using the Oxford Levels of Evidence Scale. Whenever possible, the authors created evidence tables and performed meta-analysis. Of 900 studies identified, 18 were selected for inclusion. These studies provided data from over 15,000 patients (90 % female) for analysis. Lymphadenopathy, parotid enlargement, palpable purpura, low C4 serum levels and cryoglobulins were the most consistent non-Hodgkin´s lymphoma/lymphoproliferative disease predictors. Additionally, some of the studies identified splenomegaly, low C3 serum levels, lymphopenia and neutropenia as significant prognostic factors. The detection of germinal center-like lesions in primary Sjögren Syndrome diagnostic salivary biopsies was also proposed as highly predictive of non-Hodgkin´s lymphoma. In contrast, anemia, anti-Ro, anti-La, antinuclear antibodies, rheumatoid factor, male gender and hypergammaglobulinemia were not associated with lymphoma or lymphoproliferative disease. Patients with primary Sjögren syndrome have an increased risk of lymphoma or lymphoproliferative disease compared to the general population. Ascertaining relevant and reliable predictors in this patient population would greatly facilitate the identification of patients at elevated risk for closer monitoring in the context of limited resources.

Primary Sjogren syndrome (PSS) is an autoimmune disease characterized by lymphocytic infiltration in exocrine glands, mainly the salivary and lachrymal glands, resulting in xerophthalmia and xerostomia. Occasionally, PSS has extra-glandular manifestations, including central (CNS) and peripheral nervous system (PNS) involvement. The reported prevalence varies in the literature, mainly because of heterogeneity in the diagnostic and classification criteria. Involvement of the PNS is more frequent than that of the CNS, presenting as axonal, sensory, autonomic or small fiber neuropathies and mononeuritis multiplex. CNS manifestations may be focal or diffuse and are associated with increased extra-glandular involvement and the presence of autoantibodies. Treatment is based on corticosteroids. In severe, refractory- or corticosteroid-dependant cases, immunosuppressant agents such as azathioprine or cyclophosphamide may be useful. Observational studies have suggested that rituximab is useful in some PSS extra-glandular manifestations. Currently, clinical trials with new biological agents such as belimumab and epratuzumab are being conducted in PSS.

BACKGROUND: Fungal arthritis is usually of haematogenous origin, and mainly affects patients with impaired cellular immunity or users of intravenous drugs. The infection in immunocompetent patients is generally caused by direct inoculation of the microorganism through an invasive device. The experience of azole therapy in these patients is limited. CASE REPORT: We report a case of arthritis caused by Scedosporium apiospermum characterized by its slow onset, lack of response to posaconazole and caspofungin, and its successful resolution after surgical debridement and treatment with voriconazole. CONCLUSIONS: Treatment with voriconazole and surgical debridement is an effective therapy for arthritis due to S. apiospermum.

Objective: This study aimed to investigate the effectiveness and safety of single and repeated courses of rituximab in patients with refractory lupus. Methods: LESIMAB is a multicenter, retrospective, longitudinal study of lupus patients who have not responded to standard therapy and have been treated with rituximab. Response rates at six months and at follow-up were defined as efficacy outcomes. Complete response was defined as a SELENA-SLEDAI score ≤ two and a SELENA-SLEDAI Flare Index of zero. Partial response was defined as a reduction in the SELENA-SLEDAI score of ≥four points with no new or worsening of symptoms. Adverse events were collected. Results: Seventy-three (62.9%) of 116 patients achieved a response at six months (complete in 22 and partial in 51). Ninety-seven (77.6%) of 128 patients achieved a response after a mean follow-up of 20.0 ± 15.2 months (complete in 50 and partial in 47). High baseline SLEDAI score, previous treatment with ≥100 mg/day prednisone, and no history of severe hematologic flare were associated with response after the first treatment course. The median time to response was 6.5 months (95% CI, 5.0–8.0). Thirty-seven patients (38.1%) relapsed after the first infusion. The flare was severe in seven cases and mild to moderate in 29 cases. Serious infection rate was 12.6/100 patient-years. A schedule of four weekly doses was associated with more serious infections. Six patients died: two of infection and four of lupus complications. Conclusion: Rituximab can be an effective treatment option for patients who have refractory lupus with severe or life-threatening disease with an acceptable tolerance profile.

Systemic sclerosis (SSc) is a complex autoimmune disease which genetic component has not been yet completely understood. IL6 encodes a cytokine with a crucial role in the development of autoimmunity and fibrosis and its actions mainly are controlled by IL-6 receptor (IL-6R). We aimed to investigate whether the functional genetic variants rs8192284 and rs2228044 previously associated with several autoimmune diseases, located within the IL-6 receptor (IL-6R) subunits IL6R and IL6ST genes, respectively, are involved in the susceptibility to SSc and/or its major clinical subphenotypes. A Spanish cohort including 1013 SSc patients and 1375 controls was genotyped using the TaqMan® allelic discrimination technology. SSc patients were subdivided according to the major clinical forms, autoantibody status and presence of fibrotic lung affection. Our data showed no influence of the selected variants in global SSc susceptibility (rs8192284: P=0.67, odds ratios (OR)=0.98; rs2228044: P=0.99, OR=1.00). Similarly, the clinical/autoantibody subphenotype analyses did not yielded significant results. Our data suggest that the analyzed polymorphisms may not play a significant role in the SSc susceptibility.

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease. Autoantibody production plays a critical role in its pathogenic pathways. Thus, B-cell directed biologic therapy is a logical option. The present article reviews the latest advances in the development of B-cell directed biological agents in the treatment of SLE. Rituximab has been studied in a number of open series of patients that suggest efficacy but two recent controlled clinical trials have failed to show efficacy versus placebo. In contrast, a recent placebo-controlled, double-blind, randomized trial has reported that belimumab has statistically significant efficacy versus placebo. Atacicept, a fusion protein that blocks cytokines that play a critical role in the differentiation and survival of B-cells and plasma cells, markedly reduces autoantibody levels but could increase the risk of infection. Further studies are needed to establish the role of B-cell directed biologic therapy in SLE.

Objective Shoulder pain is a common complaint, frequently caused by subacromial impingement syndrome (SIS). There are a number of physical examination (PE) manoeuvres that explore the subacromial space. MRI provides an accurate anatomic image of the subacromial space, being the current gold standard in the diagnosis of SIS. The aim of this study is to evaluate the accuracy of the PE in the diagnosis of SIS and/or subacromial-subdeltoid bursitis (SSB) confirmed by MRI. Methods Consecutive outpatients with an episode of shoulder pain were prospectively included in the study. They were examined by a rheumatologist and, within 3 days, an MRI was done. Sensitivity, specificity, positive and negative predictive values, and accuracy of PE manoeuvres were calculated using a 2 x 2 table. Results Fourteen males and 16 females were included. All the tests exhibited acceptable sensitivity. As a result Yocum manoeuvre was considered the most sensitive and most accurate for SIS. With regard to SSB, the Gerber test was the most sensitive. The majority of the PE manoeuvres showed low specificity. Conclusions Most PE manoeuvres identify reasonably well subacromial impingement of the shoulder, although, in general, they have low specificity. The Yocum test has the best sensitivity and precision. Our data suggest that imaging techniques should be recommended to better define shoulder lesions.

Objectives. To identify patterns (clusters) of damage manifestations within a large cohort of SLE patients and evaluate the potential association of these clusters with a higher risk of mortality. Methods. This is a multicentre, descriptive, cross-sectional study of a cohort of 3656 SLE patients from the Spanish Society of Rheumatology Lupus Registry. Organ damage was ascertained using the Systemic Lupus International Collaborating Clinics Damage Index. Using cluster analysis, groups of patients with similar patterns of damage manifestations were identified. Then, overall clusters were compared as well as the subgroup of patients within every cluster with disease duration shorter than 5 years. Results. Three damage clusters were identified. Cluster (80.6% of patients) presented a lower amount of individuals with damage (23.2 vs 10096 in clusters 2 and 3. P < 0.001). Cluster 2 (11.4% of patients) was characterized by musculoskeletal damage in all patients. Cluster 3 0.096 of patients) was the only group with cardiovascular damage, and this was present in all patients. The overall mortality rate of patients in clusters 2 and 3 was higher than that in cluster 1 (P < 0.001 for both comparisons) and in patients with disease duration shorter than 5 years as well. Conclusion. In a large cohort of SLE patients, cardiovascular and musculoskeletal damage manifestations were the two dominant forms of damage to sort patients into clinically meaningful clusters. Both in early and late stages of the disease, there was a significant association of these clusters with an increased risk of mortality. Physicians should pay special attention to the early prevention of damage in these two systems.

Objective The development of common variable immunodeficiency (CVID) or hypogammaglobulinemia in systemic lupus erythematosus (SLE) is rare. The purpose of this article is to provide a detailed review of lupus-associated CVID and to identify clinical characteristics and laboratory features in patients with SLE-associated CVID. Methods We describe 2 patients with SLE and CVID and review the cases published in the English literature highlighting both the demographic and the clinical characteristics and the laboratory and therapeutic aspects of this disorder. Results Detailed descriptions of 18 patients were available; 89% were females with a mean age at the onset of SLE of 23.8 years. In 50% of patients CVID developed within the first 5 years after the diagnosis of SLE. All patients had been treated with corticosteroids and 72% had also received immunosuppressive therapy. Sinopulmonary infections were the most frequent symptom. SLE disease activity decreased after the development of CVID in 67% of patients. Most patients (89%) were treated with gammaglobulin therapy. The most notable immunological feature was a reduced number or percentage of B-cells in 60% of patients. Conclusions CVID should be suspected in any SLE patient with recurrent sinopulmonary infections in the absence of SLE activity and/or immunosuppressive treatment.

Current treatment options for systemic lupus erythematosus (SLE) fail to control all the manifestations of the disease or fully prevent flares. The most extensively studied biological therapies are directed against B cells, although other biological targets have also been explored. Biological agents against tumor necrosis factor-alfa differ in their efficacy and have been associated with the generation of antinuclear and anti-dsDNA antibodies. Anti-interleukin-10 and anti-interleukin-6 agents have also been studied, with encouraging results. Abatacept, which has been approved in rheumatoid arthritis, has not shown efficacy in placebo-controlled clinical trials.

Anti-tumor necrosis factor-a (TNF) therapy has been associated with reactivation of hepatitis B virus infection. Case reports have suggested the concomitant need of lamivudine treatment in patients with HBV infection treated with antiTNFa agents. We describe a case of ankylosing spondylitis with positive HBV surface antigen (HBsAg) treated with infliximab and lamivudine. Clinical response was excellent but when lamivudine therapy was stopped, reactivation of replication viral occurred. After the reintroduction of lamivudine, viral replication was controlled and liver function tests were normalized. Preventive long-term lamivudine therapy is mandatory when anti-TNFa therapy is maintained in patients with chronic HBV infection.

Glucocorticoids (GC) are a mainstay of the therapy in rheumatoid arthritis (RA). Currently, and despite their extensive use, the discussion about the benefits and adverse effects of low dose GC in the management of RA persists. In recent years, a number of clinical trials have attempted to establish the benefits of long-term GC use as a disease-modifying antirheumatic drug in RA, and to define their side effects. Results of these clinical trials provide solid evidence that low-dose GC can inhibit radiographic damage in early RA, and that side effects of GC, when used in that clinical framework, are limited to hyperglycaemia, cataracts, and transient weight gain.