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Objectives: To compare balance, foot function and mobility in patients with rheumatoid arthritis with and without foot orthoses. Design: Randomized controlled trial. Setting: Outpatient rheumatology clinic. Subjects: A total of 94 subjects with rheumatoid arthritis were randomized; of these, 81 were included in the analyses (Intervention group: 40; Control group: 41). Intervention: The Intervention Group received custom-made foot orthoses while the Control Group received none intervention. Main measure: The “Foot Function Index,” the “Berg Balance Scale,” and the “Timed-up-and-go Test” were assessed at baseline an after four weeks. The chosen level of significance was P Results: Average (standard deviation) participant age was 56.7 (±10.6) years old and average disease duration (standard deviation) was 11.4 (± 7.2) years. Groups were similar at baseline, except for comorbidity index and race. After four weeks, significant interaction group versus time was observed for Foot Function Index (change: Intervention group: −1.23 ± 1.58; Control group: −0.12 ± 1.16 – P = 0.0012) and for Berg Balance Scale (change: Intervention group: 2 ± 3; Control group: 0 ± 3 – P = 0.0110), but not for the Timed-up-and-go Test (change: Intervention group: −1.34 ± 1.99; Control group: −0.84 ± 2.29 – P = 0.0799). Conclusion: Foot orthoses improved foot function and balance in patients with rheumatoid arthritis.

Objectives In a longitudinal case–control observational study, we evaluated the benefits of a self-management programme for hands developed for patients with SSc. Methods Patients with SSc included in the intervention group (IG) received a concise self-management programme with emphasis on hand exercises and were evaluated during 24 weeks regarding hand pain, hand function, range of motion, grip and tip and key pinch strength. Results were compared with a control group (CG) with no intervention using an analysis of variance for repeated measures with variables transformed into ranks (P ≤ 0.05). Effect sizes were calculated using Cohen’s test. Results Of 90 patients who were evaluated, seven were excluded at enrolment and 26 were excluded during the follow-up. Data from 57 subjects (IG 40, CG 17) were used for analysis. Groups were similar at baseline, except for the Scleroderma HAQ and tip and key pinch strength. Outcome improvements were noted only in the IG (P ≤ 0.05, large effect size). In the CG, variables did not change or had even worsened (hand grip strength and finger motion). Conclusions This self-management programme based on hand exercises for SSc resulted in pain reduction and hand function, strength and range of motion improvement. It can be a simple and useful intervention, especially when a regular rehabilitation programme is not available.

Objective Few studies have taken advantage of 18F-fluorodeoxyglucose positron emission tomography associated with computed tomography (18F-FDG PET/CT) to personalize patient evaluation and identify sites of more active disease in Takayasu arteritis (TA)–treated patients. This study aimed to evaluate the utility of 18F-FDG PET/CT in late acquisition in identifying sites of active disease in patients under full treatment for TA. Methods In this cross-sectional study, patients under full treatment underwent whole-body 18F-FDG PET/CT. Sites of increased 18F-FDG uptake were classified by a score of 3 on the visual scale using the liver uptake as reference. A quantitative analysis was also performed by measuring the maximum standardized uptake value (SUV) of the vascular wall of affected arteries. Disease activity using the National Institutes of Health criteria was also evaluated. Results Of the 20 patients, there were 18 female and 2 male patients, with a mean age of 43.6 (±11.58) years and a disease duration of 8.3 (±6.25) years. Thirteen participants (65%) were in inflammatory activity according to the criteria proposed by the National Institutes of Health. All patients received immunosuppressive agents, and one of them received immunobiological treatment. The highest SUV value was 6.2 in the aortic arch, and the lowest was 1.0 in the subclavian artery. The mean maximum SUV did not differ between clinically active and inactive patients. In the visual analysis, all participants had at least 1 vascular site with inflammatory activity, with an uptake ≥2 in relation to the liver. The aortic arch was the most frequently involved site. Conclusions This study showed that 18F-FDG PET/CT in late acquisition is an effective imaging method to assess TA activity even in fully treated patients.

Background/objective The epidemiology of vasculitis is variable in different geographic areas, and this issue has not been approached in Brazil yet. The objective of this study was to assess the frequency of vasculitis in specialized centers in Brazil. Methods This cross-sectional study was performed in 9 vasculitis outpatient clinics from 6 different states mainly from the Southeast and the Northeast regions of Brazil between 2015 and 2017. Diagnosis and/or classification criteria for Behcet disease (BD), Takayasu arteritis (TA), giant cell arteritis (GCA), polyarteritis nodosa (PAN), granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA), and cryoglobulinemic vasculitis (CryoVas) were used to include patients with at least 6 months of follow-up in this hospital-based survey. Results A total of 1233 patients with systemic vasculitis were included from the Southeast region. Behcet disease was the most frequent vasculitis (35.0%) followed by TA (26.4%), GPA (16.2%), PAN (5.8%), GCA (5.8%), EGPA (4.3%), MPA (3.4%), and CryoVas (3.0%). Up to 7.8% of vasculitis patients had a juvenile onset, and the frequency of vasculitides found in children and adolescents was as follows: TA (52.6%), BD (24.7%), GPA (12.4%), and PAN (10.3%). No cases of EGPA, MPA, and CryoVas were diagnosed before the age of 18 years. As a comparator, 103 vasculitis patients were included in the Northeast of Brazil where TA was found in 36.9% and BD in 31.1% of vasculitis cases. No GCA cases were found in the Northeast part of Brazil. Conclusions Similar to the epidemiology of vasculitis in Asia, BD and TA are the most frequent vasculitis in Southeastern Brazilian referral centers.

Background: Rheumatoid patients(RA)have increased rate of falls and an impaired balance. Foot orthoses are commonly used in RA. Despite the evidence of pain relief with foot orthoses, it is not clear if their use can improve or even impair balance in RA. Objectives: The aim of this study was to evaluate the effect of foot orthoses on balance of RA patients. Methods: 94 RA patients in the outpatient clinic of the Rheumatology Division of Unicamp were randomly assigned to intervention group/IG(n=48)with foot orthoses or control group/CG(n=46)without orthoses. At initial visit, subjects were assessed regarding:sociodemographic and clinical data(number of falls in last year, fear of falling, disease duration, rheumatoid factor, lmedication, visual impairment, vertigo, physical activity, body mass index, comorbidity index, foot tactile sensitivity, number of lower limbs swollen and tender joints count, disease activity-CDAI and disability-HAQ). Subjects answered The Foot Function Index-FFI and were submitted to Berg Balance Scale-BBS, the Timed Up and Go-TUG and the 5-Time Sit Down-to-Stand up-SST5 tests.IG subjects received custom made insoles according to each foot needs. After four weeks, subjects were reassessed for FFI, BBS and TUG. To compare baseline values of groups, the chi-squared test, Fisher’s exact test and Mann-Whitney test were applied.ANOVA for repeated measures was used to compare differences between groups and times for BBSTUG and FFI. Effect size was analyzed using the Cohen9s d test. All data were analyzed with a 5%level of significance. Results: 81 subjects completed the research protocol,40 in the IG and 41 in the CG. Groups were similar at baseline for most variables with exception of comorbidity index(worst index in IG) and race(p Conclusions: Foot orthoses were well accepted and worn during long periods with FFI and balance tests (BBS, TUG)improvement. Prospective placebo controlled studies are recommended to assure the possibility to use insoles as adjuvant interventions to improve balance in RA. References 1. Hennessy K, Woodburn J, et al. Custom foot orthoses for rheumatoid arthritis: A systematic review2012Mar;64(3):311–20. 2. de P Magalhaes E, Davitt M, et al. The effect of foot orthoses in rheumatoid arthritis.Rheumatology2006;45(4):449–53. 3. Clark H, Rome K, et al. A critical review of foot orthoses in the rheumatoid arthritic foot. Rheumatology2006;45(2):139–45. 4. Metli N, Kurtaran A, et al. Impaired Balance and Fall Risk in Rheumatoid Arthritis Patients. Annals of the Rheumatic Diseases2014;73:906. Disclosure of Interest: None declared

Background Feet are involved in 90%of Rheumatoid arthritis (RA) patients. The Structural Index Score(SIS) is a score that evaluates forefoot and rearfoot aspects. Although it has been used as a clinical tool to quantify foot deformities in RA, its relevance in clinical practice is uncertain. Objectives The aim of this study was to evaluate the relation of SIS with foot function, disability and physical performance tests in RA. Methods 104 RA patients of the outpatient clinic of Rheumatology/Unicamp were evaluated for SIS total, forefoot, rearfoot and its items (hallux valgus, metatarsalphalangeal (MTP) subluxation, 5th MTP exostosis, claw/hammer toe deformities, calcaneus varus/valgus angle, ankle range of motion (ARM) and planus/cavus foot deformity). Subjects also performed Foot Function Index-FFI, Health Assessment Questionnaire Disability Index-HAQ-DI, lower limb HAQ-LL-HAQ and physical tests: Berg Balance Scale-BBS, the Timed Up and Go-TUG and the 5-time sit down-to-stand up-SST5 tests.SIS items were compared with HAQ, LL-HAQ, FFI and physical tests through Kruskal- Wallis test and Spearman correlation coefficient with a 5% level of significance. Results SIS-Forefoot score did not correlate with any variables. Among the SIS-forefoot items, hallux valgus was associated with FFI-pain (p=0.007), FFI-disability(p=0.005)and FFI-total (p=0.016); MTP subluxation was weakly correlated with FFI-disability (rs=0.196) and 5th MTP exostosis was associated with FFI-pain(p=0.018). SIS-Total, SIS-Rearfoot and its associated and correlated items are shown in table 1. Conclusions It is not clear if the use of SIS may be related to function and disability in RA. Forefoot SIS did not show correlation although hallux valgus, MTP subluxation and 5th MTP exostosis may be related to foot function. Rearfoot SIS and its items seem to be most correlated with function and disability in RA. References [1] Kerry RH, et al. The foot in chronic rheumatoid arthritis:a continuing problem. The Foot1994;4:201–3. [2] Turner DE, et al. Biomechanics of the foot in rheumatoid arthritis:identifying abnormal function and the factors associated with localised disease’impact’.Clin Biomech2008;23(1):93–1003. [3] Platto MJ, et al. The relationship of pain and deformity of the rheumatoid foot to gait and an index of functional limitation. J Rheumatol1991;18:38–43. [4] Goksel Karatepe A, et al. Foot deformities in patients with rheumatoid arthritis: the relationship with foot functions. Int J Rheum Dis. 2010;13(2):158–63. Disclosure of Interest None declared

Background Rheumatoid patients(RA)are known to have an increased falls incidence with a threefold increased risk of hip fracture. Few studies have been conducted to evaluate the relation between falls, disease activity, disability and physical functioning. Objectives To evaluate the prevalence of falls in RA and its relation with disease activity, disability and physical performance tests. Methods 113 RA patients were evaluated from the outpatient clinic of the Rheumatology Division of the State University of Campinas/Unicamp. Patients were assessed for occurrence of falls in last year, fear of falling, sociodemographic and clinical data (medication, visual impairment, vertigo, physical activity, body mass index, disease duration, rheumatoid factor, lower limb swollen and tender joints, foot tactile sensitivity, disease activity-CDAI and disability-HAQ). Subjects were submitted to Berg Balance Scale-BBS, the Timed Up and Go Test-TUG and 5-Time Sit Down-to-Stand Up Test-SST5 and were divided in “Fallers” and “Non-Fallers” groups. For comparison of groups the chi-squared test, Fisher’s exact test and Mann-Whitney were used. Univariate linear regression and multivariate analysis were used to analyse the relation between sociodemographic, clinical data and physical tests with the occurrence of falls. Kruskal- Wallis test was used for analysis of the association of BBS, TUG and SST5 with CDAI and HAQ. The data were analysed with a 5% level of significance. Results 52.21% reported the occurrence of falls in the past 12 months and 62.8%were fearful of falling. Comparing “Fallers” and “Non-Fallers”, significant differences were noted for HAQ(p=0.0242), fear of falling(p=0.0196) and BBS(p=0.0120). After univariate logistic regression there was association of falls with income(OR 1.05), HAQ(OR 1.945), fear of falling(OR 2.586) and TUG (OR 1.09). In multivariate model, income was independently linked to falls(OR 1.07). BBS, TUG, SST5 were correlated with CDAI and HAQ(p Conclusions RA patients have high prevalence of falls and fear of falling. Income was an independent fall risk factor. BBS seems to be higher among fallers and TUG can be considered a fall risk predictor. BBS, TUG and SST5 are related to CDAI and HAQ. CDAI does not seems to be a good instrument to predict falls due to its variability over time. In clinical practice, HAQ can be a valuable tool to recognise patients with an increased risk of falls. References [1] Stanmore EK, Oldham J, Skelton DA, et al. Risk factors for falls in adults with rheumatoid arthritis: a prospective study. Arthritis Care Res2013Aug;65(8):1251–8. [2] Brenton-Rule A, Dalbeth N, Menz HB, et al. The incidence and risk factors for falls in adults with rheumatoid arthritis: a systematic review. Semin Arthritis Rheum2014;44:389–98. [3] Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J AmGeriatr Soc1991; 39:142–8.16. [4] Berg KO, Maki BE, Williams JI, et al. Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil1992;73:1073–1080. [5] Bohannon RW. Test-retest reliability of the five-repetition sit-to-stand test: a systematic review of the literature involving adults. J Strength Cond Res2011; 25:3205–7. Disclosure of Interest None declared

IntroductionOtorhinolaryngological manifestations of rheumatologic diseases represent a great challenge not only to the generalistphysician but also to the ENT doctor andrheu- matologist. They often represent early manifestations of an autoimmune disorder which requires prompt and aggressive immunosuppressive treatment. Auditory, nasal, laryngeal and eye symptoms can be the first manifestation of rheumatic diseases and their proper assessment helps the doctor to identify signs of disease activity. The objective of this study is to identify the ENT manifestations in patients with rheumatic diseases in a high comple- xity hospital, regarding facilitating an early diagnosis and treatment.MethodsWe performed clinical and complete otorhinolaryngological evaluations in pa- tients selected from the outpatient rheumatology in a standardized manner by the use of a standardized form filling during the secondhalf of 2010.ResultsIn the study group, systemic lupus erythematosus (SLE) patients had predomi- nantly laryngeal manifestations, while patients with Sjögren's syndrome showed a higher prevalence of otologic manifestations. Changes in audiometric tests were found in 53% of Wegener's granulomatosis (WG) patients, 80% of relapsing polychondritis (RP), 33% of systemic lupus erythematosus (SLE) and 50% of Churg-Strauss syndrome (SCS). Regarding nasal alterations, these were found so prevalent in all conditions, especially Churg-Strauss syndrome.Discussion and conclusionThis study demonstrated that most patients treated in our hospi- tal has the ENT signs and symptoms commonly associated in previous studies on rheuma- tic diseases, but further studies with a larger number of patients must be made to establish such relations.

The aim of this study was to determine the demographic and clinical characteristics in patients diagnosed with Behçet's disease (BD) in Brazil. We performed a retrospective review of all the patients' records with BD diagnosed from 1988 to 2010 in the Rheumatology Department at the State University of Campinas (UNICAMP). All patients had to fulfill the International Study Group for Behçet's disease diagnostic criteria. Eighty-seven patients were included in the study. The female/male ratio was 1.18:1, and the mean age at the onset of the disease onset was 28.03 ± 7.57 years. Oral aphthosis was the most frequent manifestation (100%). Genital aphthosis was also frequent (77%), followed by pseudofolliculitis (47.67%). Ocular symptoms were present in 80% and neurological manifestations in 31.03% of the patients. Arthralgia was reported in 31.03% and arthritis in 13.79% of the cases. Vascular involvement was seen in 13.95% of the patients. Only 1.14% had gastrointestinal involvement. This series, from a South American country, showed a similar general pattern of the BD to those found in different endemic areas in the world, with a high frequency of ocular and neurological manifestations.

A 43-year-old woman reported pain in the right hypochondrium, which had started 3 years before and had been worsening for the past few days. Claudication in the superior and inferior limbs, diffuse myalgia, dyspnea, precordialgia followed by dizziness and visual turbidity were added to the clinical picture. In the physical examination bilateral carotid bruit was observed, abdominal aorta murmur and the decrease of the right radial and left pedis pulses and arterial hypertension with difference in the diastolic pressure between limbs >10 mmHg was also observed. On cardiac catheterisation with aortography, right coronary with proximal parietal irregularities, slight pressure increase in right chambers and pulmonary artery, preserved left ventricle contractility, competent valves, carotid and subclavian partial obstruction, severe narrowing of the abdominal aorta below the diaphragm (80%) and right renal artery significant stenosis were observed. Takayasu’s arteritis (TA) diagnosis was established according to the ACR criteria based on the clinical symptomatology, on physical and image test findings. Two years later she presented malar rash, photosensitivity, nephropathy, leukopenia, lymphopenia and hemolytic anemia confirming the systemic lupus erythematosus (SLE) diagnosis. TA coexisting with SLE has rarely been reported.

The aim of this report is to verify the demographic, clinical, laboratorial and histopathological findings of patients with CSS followed in a University Clinical Hospital. We reviewed the medical records of all patients with the diagnosis of CSS. Only patients who fulfilled ACR criteria were included. Five Caucasian patients were found, with a sex ratio M/F: 3/2. The mean age at disease onset was 46 years old (40 to 55) and the mean time of follow-up was 2.37 years (0.25 to 6). General symptoms, asthma, peripheral neuropathy and skin lesions were the most common clinical findings in all patients. Cardiovascular, gastrointestinal and renal involvement was found in one patient each. All patients presented hypereosinophilia (> 10%) and p-ANCA was present in 3 patients. The chest x-ray showed pulmonary parenchymal infiltrate in 2 cases and in 1 of them an unilateral pleural effusion. Skin biopsies showed extravascular eosinophylia in 3 out of 4. All patients were treated with prednisone and in 3 it was added immunosuppressive drug. No patient died during the follow-up. CSS is a rare disease with a multivisceral involvement and asthma is the main and the earliest symptom. General symptoms and involvement of skin and peripheral nerves were found in all patients. Renal, cardiovascular and gastrointestinal involvement was rare, differently from the literature series where these findings are more frequent. In spite of the CSS being a serious and life-threatening disease, these patients presented adequate response to the treatment and a favorable outcome.

Parvovirus B19 (B19) has been implicated in the aetiopathogenesis of some cases of systemic vasculitis, mainly giant cell arteritis.1 A positive serological test for B19 has been reported in a few patients with polyarteritis nodosa (PAN).2–4 As far as we know no studies of B19 DNA in tissue samples of patients with PAN have been published, so we used a nested polymerase chain reaction (PCR) approach to screen for B19 DNA in fixed paraffin embedded tissue samples from patients with PAN and microscopic polyangiitis (MPA). The diagnosis was based on the Chapell-Hill Consensus Conference guidelines.5 Only tissue samples from patients with vasculitis were used for DNA preparations. DNA was extracted using a commercial kit (DNeasy tissue kit, Quiagen). A nested PCR for B19 was carried out using a previously published set …

Polyarteritis nodosa (PAN) is a systemic vasculitis of unknown etiology. Although gastrointestinal involvement may be seen in half of the cases of PAN, vasculitis of the gallbladder at the disease onset is a rare presentation. We report a case of a 48-year-old man who was admitted due to acute cholecystitis. He had complained of myalgia, fever and weight loss for about one month prior to admission. At physical examination, mild hypertension and calf pain were noted. He underwent a cholecystectomy; histopathological evaluation disclosed necrotizing vasculitis suggestive of PAN. We emphasize that cholecystitis may be part of the initial presentation of systemic vasculitis.

The authors report a 38-year-old white man with ankylosing spondylitis (AS) who presented with recurrent ischaemic optic neuritis. The initial diagnosis was of multiple sclerosis, but further investigation showed serology and cerebrospinal fluid culture positive for syphilis. After treatment for tertiary syphilis with penicillin, there was complete remission of the ocular symptoms. This case illustrates the differential diagnosis of optic neuritis in AS and supports the relevance of investigating infectious diseases in the management of ischaemic optic neuritis.

ResumoIntroduçãoAs manifestações otorrinolaringológicas de doenças reumáticas representam um grande desafio não só ao médico generalista, mas também ao otorrinolaringologista e ao reumatologista. Frequentemente representam manifestações iniciais de uma desordem autoimune que exige um tratamento imunossupressor imediato e agressivo. Sintomas auditivos, nasais, laríngeos e oculares podem ser a primeira manifestação de doenças reumá‐ ticas, e sua correta avaliação auxilia o médico a identificar sinais de atividade da doença. O objetivo deste trabalho foi identificar as manifestações otorrinolaringológicas em pacientes com doenças reumáticas em um hospital de alta complexidade, no que se refere a facilitar diagnóstico e tratamento precoces.MétodosForam realizadas avaliações clínicas e otorrinolaringológicas completas em pa‐ cientes selecionados no ambulatório de reumatologia, no segundo semestre do ano de 2010, de forma padronizada e com utilização de um formulário de preenchimento normatizado. Resultados: No grupo estudado, pacientes com LES apresentaram predominantemente ma‐ nifestações laríngeas, enquanto pacientes com síndrome de Sjögren apresentaram predo‐ mínio das manifestações otológicas (100% dos casos). As alterações de exames audiométri‐ cos são encontradas em 53% dos casos portadores de GW, 80% de PR, 33% de LES e 50% de SCS. Quanto às alterações nasais, estas foram encontradas de forma prevalente em todas as patologias, principalmente a síndrome de Churg‐Strauss.Discussão e conclusãoEste estudo demonstrou que a maioria dos pacientes em seguimento em nosso serviço apresenta os sinais e sintomas otorrinolaringológicos comumente rela‐ cionados em trabalhos prévios sobre doenças reumáticas, porém novos estudos com um número maior de pacientes devem ser feitos para comprovar tais relações.AbstractIntroductionOtorhinolaryngological manifestations of rheumatologic diseases represent a great challenge not only to the generalistphysician but also to the ENT doctor andrheu‐ matologist. They often represent early manifestations of an autoimmune disorder which requires prompt and aggressive immunosuppressive treatment. Auditory, nasal, laryngeal and eye symptoms can be the first manifestation of rheumatic diseases and their proper assessment helps the doctor to identify signs of disease activity. The objective of this study is to identify the ENT manifestations in patients with rheumatic diseases in a high com‐ plexity hospital, regarding facilitating an early diagnosis and treatment.MethodsWe performed clinical and complete otorhinolaryngological evaluations in pa‐ tients selected from the outpatient rheumatology in a standardized manner by the use of a standardized form filling during the secondhalf of 2010.ResultsIn the study group, systemic lupus erythematosus (SLE) patients had predomi‐ nantly laryngeal manifestations, while patients with Sjögren's syndrome showed a higher prevalence of otologic manifestations. Changes in audiometric tests were found in 53% of Wegener's granulomatosis (WG) patients, 80% of relapsing polychondritis (RP), 33% of systemic lupus erythematosus (SLE) and 50% of Churg‐Strauss syndrome (SCS). Regarding nasal alterations, these were found so prevalent in all conditions, especially Churg‐Strauss syndrome.Discussion and conclusionThis study demonstrated that most patients treated in our hospi‐ tal has the ENT signs and symptoms commonly associated in previous studies on rheumat‐ ic diseases, but further studies with a larger number of patients must be made to establish such relations.