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Background The goal of the treatment of rheumatoid arthritis (RA) is remission, however the remission induction for established RA (eRA) patients with long disease duration and significant radiographic damage is difficult. One of the reasons for this is that Patient Global Assessment score (PtGA) continues to be high even after the synovitis resolves through appropriate treatment, because of disability or pain from the structural damage. Although such high PtGA of eRA patients is thought to be acceptable, there is little evidence which supports this concept. Objectives To evaluate whether high PtGA of eRA patients is acceptable by assessing synovitis using ultrasound sonography (US). Methods Three hundred and thirty two RA patients were recruited with informed consent. Bilateral 2–5 MCP, wrist, ankle, and 2–5MTP joints were scanned by using the Aplio500 (TOSHIBA) with a 12 MHz transducer. Power Doppler (PD) images were obtained by Superb Micro-vascular Imaging (SMI). Gray scale (GS) and PD images were scored using a 0–3 semi-quantitative scale. Clinical information was obtained from the Kyoto University Rheumatoid Arthritis Management Alliance (KURAMA) database, which is based on the assessment by physicians who were blind to the US results. We defined “Semi-Boolean remission (SBR)” as the condition which is composed of 3 elements of Boolean remission (BR) criteria, excluding PtGA. All the patients were classified into 1–4 Steinbrocker stages according to their joint X-rays. Results The number of patients who fulfilled BR or SBR criteria were 99 and 122, respectively. As shown in table 1, age, disease duration, total GS score, and total PD score were virtually the same between the two groups. PtGA become higher in accordance with the stages (P Conclusions PtGA did not always reflect the activity of synovitis. This was not limited to eRA but also to RA without radiographic damage. However, we must be careful as higher total PD scores were seen in eRA patients even though they were thought of as being in BR or SBR. This result means that a certain portion of active eRA patients are misclassified as being in remission. Before accepting the high PtGA, we should use US for correct evaluation of eRA. Disclosure of Interest None declared

Patients with primary sclerosing cholangitis (PSC) are at an increased risk for biliary tract carcinoma. The preoperative diagnosis of a biliary tract tumor as a malignancy is difficult, even using new modalities such as multidetector computed tomography (MD-CT), magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiography (ERC), and (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET). Surgery is considered to be first line of treatment when these examinations suggest the presence of malignancy in the biliary tract, depending on both the curability of the cancer and the impaired liver function due to PSC. The management of gallbladder masses in patients with PSC remains problematic due to difficulties with the precise diagnosis and adequate surgery. Xanthogranulomatous cholecystitis (XGC) is a type of chronic cholecystitis, and sometimes coexists with gallbladder cancer. It is very difficult to make a preoperative diagnosis differentiating these two diseases. This report presents the case of a patient with XGC, who had been suspected of having gallbladder cancer before surgery, because the tumorous lesion emerged within a year and showed a focally increased uptake by FDG-PET during the follow up for PSC for years. This is the first case of XGC discovered during treatment for PSC.

Background Anti-cyclic citrullinated peptide antibody (aCCP) is a widely-used diagnostic marker for rheumatoid arthritis (RA). In spite of its very high specificity, it is also reported that 5 to 10% of non-RA connective tissue disease (CTD) patients are positive for aCCP [1]. It is unknown whether such aCCP-positive non-RA CTD patients may develop RA later. There are few reports that referred long term outcome of aCCP-positive CTD patients. Objectives To investigate whether aCCP-positive non-RA CTD patients finally develop RA, and to find out predictive factors of RA development. Methods Non-RA CTD patients were selected from our CTD database of Kyoto University as of December 2012. Anti-CCP was measured by the second generation ELISA kit (MESACUP-2 test CCP; MBL Inc., Japan). HLA-DRB1 allele was typed by WakFlow system and the shared epitope (SE) was defined by the HLA-DRB1 alleles shown in the reference [2]. Clinical information was obtained from the clinical records and also the questionnaire to the attending doctors. Results 842 CTD patients with aCCP information were enrolled. 58 patients had fulfilled the 1987 ACR revised criteria of RA and had been followed as overlap cases, of which 35 patients (60%) were positive for aCCP. On the other hand, out of 784 patients who had not fulfilled the RA criteria, 37 patients (4.7%) were positive for aCCP. Details are shown in the [Table 1][1] and [Figure 1][1]. During the average follow-up period of 4.8 years, none of the 37 non-RA CTD patients except one case developed RA by fulfilling the 1987 ACR revised RA criteria. Hands and feet X-ray were taken in 27 out of the 37 non-RA CTD patients, and none of them have developed bone erosions. We compared the clinical characteristics between 36 aCCP-positive RA/CTD overlapped patients and 36 aCCP-positive non-RA CTD patients, and the former showed significantly lower rheumatoid factor (RF) positivity, lower incidence of joint symptoms, less DMARDs usage, and more glucocorticoid usage. Titer of aCCP was not significantly different between these two groups. HLA DRB1 allele was typed in 26 out of 36 non-RA CTD patients and 28 out of 36 RA/CTD overlapped patients. The number of patients possessing SE were 8 (31%) and 18 (64%), respectively, the deference of which is statistically significant (p=0.01). ![Figure][2] Conclusions From our retrospective observation of follow-up period of 4.8 years in average, only one of 37 aCCP-positive non-RA CTD fulfilled the 1987 ACR revised RA criteria, but without bone erosions. The frequency of SE was significantly different between non-RA CTD patients and RA/CTD overlapped patients, which may suggest the utility of HLA typing to predict the future RA development. Because SE bind to citrullinated antigens [3], these results may also suggest that the epitope of aCCP in non-RA CTD is not dependent on citrullination. References 1. Aggarwal R. Arthritis Rheum (2009) 61: 1472-1483. 2. Terao C. Ann Rheum Dis (2011) 70: 2134-2139. 3. Scally S W. J Exp Med (2013) 210: 2569-2582. Disclosure of Interest None declared [1]: #F1 [2]: pending:yes