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ObjectiveRheumatologists play a pivotal role in the management of patients with psoriatic arthritis (PsA). Due to time constraints during clinic visits, the skin may not receive the attention needed for optimal patient outcome. Therefore, the aim of this study was to select a set of core questions that can help rheumatologists in daily rheumatology clinical practice to identify patients with PsA with a high skin burden.MethodsBaseline data from patients included in the Dutch South West Psoriatic Arthritis (DEPAR) cohort were used. Questions were derived from the Skindex-17 and Dermatology Life Quality Index (DLQI) questionnaires. Underlying clusters of questions were identified with an exploratory principal component analysis (PCA) with varimax rotation, after which a 2-parameter logistic model was fitted per cluster. Questions were selected based on their discrimination and difficulty. Subsequently, 2 flowcharts were made with categories of skin burden severity. Clinical considerations were specified per category.ResultsIn total, 413 patients were included. The PCA showed 2 underlying clusters: a psychosocial domain and a domain assessing physical symptoms. We selected these 2 domains. The psychosocial domain contains 3 questions and specifies 4 categories of skin burden severity. The physical symptoms domain contains 2 questions and categorizes patients in 1 out of 3 categories.ConclusionWe have selected a set with a maximum of 5 questions that rheumatologists can easily implement in their consultation to assess skin burden in patients with PsA. This practical guide makes the assessment of skin burden more accessible to rheumatologists and can aid in clinical decision making.

Objectives Paternal preconception health is recognized as an important contributor to pregnancy outcomes. Nonetheless, pregnancy outcomes of partners of men with inflammatory arthritis (IA) have never been studied. Our objective was to describe the pregnancy outcomes of partners of men diagnosed with IA. Methods We performed a multicentre cross-sectional retrospective study conducted in the Netherlands. Men with IA who were over 40 years old that reported at least one positive pregnancy test were included. To analyse the impact of IA on pregnancy outcomes, pregnancies were classified into two groups: pregnancies conceived after the diagnosis of IA and before the diagnosis of IA. Results In total, 408 male participants diagnosed with IA reported 897 singleton pregnancies that resulted in 794 live births. Pregnancies conceived after the diagnosis of IA had higher rate of miscarriage (12.27 vs 7.53%, P = Conclusions This is the largest study to describe the pregnancy outcomes of partners of men diagnosed with IA and the first to demonstrate that paternal IA is associated with a higher risk of miscarriage. Notwithstanding, the overall rate of miscarriage reported in our study could be comparable to previously reported population estimates.

Objectives Psoriasis impacts health-related quality of life (HRQoL) in PsA patients. However, this is not adequately measured with a general HRQoL questionnaire. The aim of this study was to quantify the degree of psoriasis evolution in PsA patients over the first year of follow-up and to evaluate whether the impact of psoriasis on HRQoL can be adequately measured with a dermatology-specific HRQoL questionnaire. Methods Data were used from PsA patients in the Dutch south west Early Psoriatic Arthritis cohort. Psoriasis severity was measured with the Psoriasis Area and Severity Index (PASI). Dermatology-specific HRQoL was assessed with the Skindex-17 questionnaire. We used a Sankey diagram to illustrate the evolution of psoriasis severity during the first year of follow-up. To assess the association between psoriasis severity and the symptoms and psychosocial subscale of the Skindex-17, a linear regression analysis with hierarchical variable selection and zero-inflated negative binominal regression analysis were performed, respectively. Results We included 644 patients; 109 (17%) patients had no psoriasis (PASI = 0), 456 (71%) had mild psoriasis (PASI 12). Psoriasis severity did not fluctuate much during the first year. PASI was significantly associated with both subscales of the Skindex-17 at baseline and 12 months. Conclusion Psoriasis severity in PsA patients is mostly mild but impacts HRQoL when measured using a dermatology-specific HRQoL questionnaire. For optimal management of PsA patients, we recommend rheumatologists acquire information on skin burden by using a dermatology-specific HRQoL questionnaire.

Background: Considering the importance of getting the right patient at the right location to maintain and optimize quality of life of inflammatory arthritis patients, appropriate referral by general practitioners is essential. This study aims to assess the effect and cost effectiveness of different referral strategies for inflammatory arthritis in primary care patients. Methods: This study follows a cluster randomized controlled trial design. General practitioners from primary care centers in Southwest-The Netherlands are randomly assigned to either one of the two strategic interventions for referring adult patients who are in the opinion of the general practitioner suspected of inflammatory arthritis: 1) Standardized digital referral algorithm based on existing referral models PEST, CaFaSpA and CARE; 2) Triage by a rheumatologist in the local primary care center. These interventions will be compared to a control group, e.g. usual care. The primary outcome is the percentage of patients diagnosed with inflammatory arthritis by the rheumatologist. Secondary outcomes are quality of life as a patient reported outcome, work participation and healthcare costs. These data, including demographic and clinical parameters, are prospectively collected at baseline, three, six, and twelve months. Discussion: If this study can demonstrate improvements in appropriate referrals to the rheumatologist, thereby improving cost-effectiveness, there is sufficient supporting evidence to implement one of the referral strategies as a standard of care. Finally, with these optimization strategies a higher quality of care can be achieved, that might be of value for all patients with arthralgia. Trial Registration: NCT03454438, date of registration: March 5, 2018. Retrospectively registered: https://clinicaltrials.gov/ct2/show/NCT03454438?term=NCT03454438&draw=1&rank=1.

Objectives The squeeze test of MTP joints is frequently used because it is easy and cheap. It is traditionally perceived as a test for synovitis. Besides classic intra-articular synovitis, also tenosynovitis and intermetatarsal bursitis (IMB) represent synovial inflammation, albeit juxta-articularly located. Both are frequently present in RA and occasionally in other arthritides. Therefore we hypothesized that tenosynovitis and IMB contribute to a positive MTP squeeze test. Methods A cross-sectional study design was used. A total of 192 early arthritis patients and 693 clinically suspect arthralgia patients underwent the MTP squeeze test and forefoot MRI at first presentation. MRI measurements in age-matched healthy controls were used to define positivity for synovitis, tenosynovitis and IMB. Logistic regression was used. Results In early arthritis patients, synovitis [odds ratio (OR) 4.8 (95% CI 2.5, 9.5)], tenosynovitis [2.4 (1.2, 4.7)] and IMB [1.7 (1.2, 2.6)] associated with MTP squeeze test positivity. Synovitis [OR 3.2 (95% CI 1.4, 7.2)] and IMB [3.9 (1.7, 8.8)] remained associated in multivariable analyses. Of patients with a positive MTP squeeze test, 79% had synovitis or IMB: 12% synovitis, 15% IMB and 52% both synovitis and IMB. In clinically suspect arthralgia patients, subclinical synovitis [OR 3.0 (95% CI 2.0, 4.7)], tenosynovitis [2.7 (1.6, 4.6)] and IMB [1.7 (1.2, 2.6)] associated with MTP squeeze test positivity, with the strongest association for synovitis in multivariable analysis. Of positive MTP squeeze tests, 39% had synovitis or IMB (10% synovitis, 15% IMB and 13% both synovitis and IMB). Conclusion Besides synovitis, IMB contributes to pain upon compression in early arthritis, presumably due to its location between MTP joints. This is the first evidence showing that MTP squeeze test positivity is not only explained by intra- but also juxta-articular inflammation.

Objectives The prevalence of psoriatic arthritis (PsA) is the same in men and women; however, the latter experience a higher burden of disease and are affected more frequently by polyarthritis. Here, we performed an early PsA cohort analysis to assess sex-related differences in demographics, disease characteristics, and evolution over 1 year including applied treatment strategies. Methods Our study is embedded in the Dutch south-west Early Psoriatic Arthritis cohoRt. We described patient characteristics and treatment decisions. For the comparison across sexes and baseline and 1 year follow-up, appropriate tests depending on the distribution were used. Results Two hundred seventy-three men and 294 women with no significant differences in age and ethnicity were included. Women reported significantly longer duration of symptoms before diagnosis and significantly higher tender joint count, a higher disease activity, higher levels of pain, and lower functional capacity. Although minimal disease activity (MDA) rates increased over time for both sexes, MDA remained significantly more prevalent among men at 1 year (58.1% vs 35.7%, p ). Initially, treatment strategies were similar in both sexes with methotrexate being the most frequently used drug during the first year. Women received methotrexate for a shorter period [196 (93–364) vs 306 (157–365), p ] and therefore received a lower cumulative dose compared to men. Retention time was shorter for all DMARDs, and women had a delayed start on b-DMARDs. Conclusion After 1 year of standard-of-care treatment, women did not surpass their baseline disadvantages. Despite the overall improvement, they still presented higher disease activity, higher levels of pain, and lower functional capacity score than men. The nature of these findings may advocate a need for sex specific adjustment of treatment strategies and evaluation in early PsA patients.

Achieving low disease activity (LDA) is important in patients with psoriatic arthritis. It is of value to know if health-related quality of life (HRQoL) of patients who reached musculoskeletal low disease activity can be further improved by additionally achieving remission of their psoriasis. So, the aim of this study was to assess HRQoL in patients with active psoriasis who reached disease activity in psoriatic arthritis (DAPSA) LDA after one year of follow-up.Data were collected from the Dutch south west Psoriatic Arthritis cohort. Musculoskeletal disease activity was measured using DAPSA. Patients who reached DAPSA-LDA after one year were divided based on reaching psoriasis remission (Psoriasis Area and Severity Index [PASI]1). HRQoL and work productivity were compared between both groups.After one year, 230 (44%) patients with active psoriasis at baseline reached DAPSA-LDA, of which 108 (47%) patients achieved psoriasis remission. The group of patients with active psoriasis (n=122, 53%) contained more men (p=0.023) and scored lower on the 12-item Psoriatic Arthritis Impact of Disease questionnaire (p=0.012). On the Skindex-17 psychosocial subscale, 31% experienced moderate to high impairment and on the symptoms subscale 28% experienced a lot of symptoms. Work productivity did not differ between both groups.The majority of patients with DAPSA-LDA and active psoriasis after one year has a good HRQoL. However, a proportion of these patients still experiences considerable skin burden. We recommend rheumatologists to continue assessing and treating psoriasis to reduce skin burden in PsA patients who achieved musculoskeletal low disease activity.

ObjectivesThe impact of inflammatory arthritis (IA) on male fertility remains unexplored. Our objective was to evaluate the impact of IA on several male fertility outcomes; fertility rate (number of biological children per man), family planning, childlessness and fertility problems.MethodsWe performed a multicentre cross-sectional study (iFAME-Fertility). Men with IA 40 years or older who indicated that their family size was complete were invited to participate. Participants completed a questionnaire that included demographic, medical and fertility-related questions. To analyse the impact of IA on fertility rate, patients were divided into groups according to the age at the time of their diagnosis: ≤30 years (before the peak of reproductive age), between 31 and 40 years (during the peak) and ≥41 years (after the peak).ResultsIn total 628 participants diagnosed with IA were included. Men diagnosed ≤30 years had a lower mean number of children (1.32 (SD 1.14)) than men diagnosed between 31 and 40 years (1.60 (SD 1.35)) and men diagnosed ≥41 years (1.88 (SD 1.14)).This was statistically significant (p=0.0004).The percentages of men diagnosed ≤30 and 31–40 years who were involuntary childless (12.03% vs 10.34% vs 3.98%, p=0.001) and who reported having received medical evaluations for fertility problems (20.61%, 20.69% and 11.36%, p=0.027) were statistically significant higher than men diagnosed ≥41 years.ConclusionsThis is the first study that shows that IA can impair male fertility. Men diagnosed with IA before and during the peak of reproductive age had a lower fertility rate, higher childlessness rate and more fertility problems. Increased awareness and more research into the causes behind this association are urgently needed.

ObjectivesMethotrexate (MTX) is currently the recommended first-line therapy for treating psoriatic arthritis (PsA), despite lacking clear evidence. No estimates of efficacy of MTX in usual care and no clear MTX responsive clinical or laboratory variables are currently available. This study describes the response to MTX monotherapy in newly diagnosed patients with PsA in usual care. Second, we compared clinical variables and cytokine profiles in patients responding and not responding to MTX monotherapy.MethodsWe used data collected in the Dutch southwest Early Psoriatic Arthritis cohoRt study to select patients with PsA with oligoarthritis or polyarthritis, and at least 1 year follow-up. We analysed disease activity at 6 months of patients who started MTX monotherapy and still used MTX monotherapy 1 year after diagnosis. Cytokine profiles were determined at baseline and after 3 and 6 months with a bead-based multi-immunoassay.ResultsWe identified 219 patients of which 183 (84%) patients started MTX monotherapy within 6 months after diagnosis. 90 patients used MTX monotherapy throughout the first year of which 44 patients (24%) reached minimal disease activity(MDA) at 6 months, decreasing to 33 patients (18%) after 1 year. Non-responders had significantly higher concentrations of interleukin (IL) 23 and IL-10 before and during MTX therapy.ConclusionsOur results showed that only 18% of patients with PsA are in sustained MDA after 1 year of MTX monotherapy and non-responders more often had IL-23-driven disease. Our results indicate the need for more treat-to-target and personalised therapy strategies in PsA.

Objective: This paper describes the baseline demographics, clinical characteristics, and patient-reported outcomes (PROs) according to clinical phenotype of patients with early psoriatic arthritis (PsA) for the purpose of creating a decision support system for daily clinical practice. Method: Patients with newly diagnosed PsA were included in the Dutch south west Early Psoriatic ARthritis (DEPAR) study. No classification criteria were applied, to ensure collection of real-world data on demographics, medication, clinical characteristics, and PROs. An IT infrastructure facilitated data collection. Results: We described 527 patients, categorized according to the clinical phenotype stated by the rheumatologist at the time of diagnosis, namely monoarthritis (15%), oligoarthritis (40%), polyarthritis (23%), enthesitis (10%), axial disease (2%), and dactylitis (10%). Overall psoriasis severity was mild and 83 patients (16%) had no psoriasis. Short-term sick leave (> 1 day per 4 weeks) was 17% and long-term sick leave (> 4 weeks) was 4%. The group with phenotype enthesitis reported the longest duration of complaints, had the highest fatigue scores, and contained the highest percentage of patients with a Hospital Anxiety and Depression Scale (HADS) anxiety score ≥ 8 and depression score ≥ 8. Conclusion: PsA patients presenting at outpatient clinics in the Netherlands had a mild degree of psoriasis, with impairment of quality of life and work productivity. Most patients presented with phenotype oligoarthritis. Those presenting with phenotype enthesitis more often reported scores suggestive of an anxiety or depression disorder and fatigue. It is important for attending rheumatologists to be aware of these differences when assessing patients with PsA.

Objective: To determine the impact of stopping tumor necrosis factor inhibitor (TNFi) treatment on patient-reported outcomes (PROs) of physical and mental health status, health utility, pain, disability and fatigue in patients with established rheumatoid arthritis (RA). Methods: In the pragmatic 12-month POET trial, 817 RA patients with ≥6 months of remission or stable low disease activity were randomized 2:1 to stopping or continuing TNFi. In case of flare, TNFi was restarted at the discretion of the rheumatologist. PROs were assessed every 3 months. Results: TNFi was restarted within 12 months in 252/531 patients (47.5%) in the stop group. At 3 months, mean PRO scores were significantly worse in the stop group and a larger proportion of patients experienced a minimal clinically important difference (MCID) on all PROs. Effect sizes (ES) were strongest for health utility (ES = -0.24) and pain (ES = -0.30). Mean scores improved again after this point but disability scores remained significantly different at 12 months. After 12 months, the relative risk of experiencing a MCID ranged from 1.16 for mental health status to 1.58 for fatigue. Mean PRO scores for patients restarting TNFi within 6 months were no longer significantly different from those that did not restart TNFi at 12 months. Conclusion: Stopping TNFi had a significant negative short-term impact on a broad range of PROs. Long-term negative consequences appeared to be limited and outcomes in patients needing to restart TNFi within the first 6 months tended to be restored at 12 months. This article is protected by copyright. All rights reserved.

Objectives: We aimed to describe sonographic structural and inflammatory changes in entheses of patients with recently diagnosed psoriatic arthritis (PsA), patients with established PsA, and young healthy volunteers, and to investigate whether the MAdrid Sonographic Enthesitis Index (MASEI) enables us to distinguish these groups in an extreme comparison. Method: New and established PsA patients and healthy volunteers (aged 20–30 years) were recruited. The triceps, quadriceps, patellar, Achilles and elbow extensor tendon insertion, and plantar fascia entheses were investigated sonographically for structural changes, erosions, calcifications, increased thickness, bursitis, and power Doppler (PD) signal according to the MASEI. Results: The study included 25 new and 25 established PsA patients, and 25 healthy volunteers. Increased thickness and PD signal in knee entheses were common for patients and healthy volunteers, while changes at other locations predominantly occurred in patients only. PD was recoded (1, one spot; 1.5, two or three spots; 2, confluent signal; 3, severe confluent signal) and thickness of knee entheses excluded. This resulted in different modified MASEI scores between PsA patients and young healthy controls: median (interquartile range) modified MASEI of 13 (10–22.5) in new PsA, 13.5 (9.5–18) in established PsA, and 3 (1–8.5) in healthy volunteers (p = 0.002). Conclusions: Structural ultrasound changes and PD in entheses are common in both new and established PsA and healthy controls. MASEI score did not differentiate PsA patients from young healthy volunteers. After recoding of PD severity and excluding thickness of knee entheses, marked differences between PsA patients and healthy controls were observed.

Objective.Psoriatic arthritis (PsA) is a multifaceted disease. Affecting joints, skin, entheses, and dactylitis, its effect on health-related quality of life (HRQOL) could be substantial. We aim to assess HRQOL in patients newly diagnosed with PsA and analyze its associations with disease manifestations.Methods.Data collected at time of diagnosis from patients with PsA included in the Dutch south-west Early Psoriatic Arthritis cohort (DEPAR) study were used. HRQOL was assessed using 8 domains of the Medical Outcomes Study Short Form-36 (SF-36) questionnaire. Patients were classified based on primary manifestation in arthritis subtypes (i.e., mono-, oligo-, or polyarthritis) and other subtypes (i.e., enthesitis, dactylitis, and axial disease). In all patients, presence of arthritis, enthesitis, dactylitis, psoriasis, and chronic inflammatory back pain was determined. Multivariable linear regression was used to determine associations of PsA manifestations with HRQOL.Results.Of 405 patients, primary manifestation was peripheral arthritis in 320 (78 monoarthritis, 151 oligoarthritis, and 91 polyarthritis), enthesitis in 37, axial disease in 9, and dactylitis in 39. Mean scores of SF-36 domains were lower than the Dutch reference population and similar across arthritis subtypes. A higher number of enthesitis locations and tender joints, and presence of chronic back pain, were independently associated with worse SF-36 scores. Psoriasis and dactylitis were not associated with worse scores.Conclusion.HRQOL was diminished in PsA at time of diagnosis compared to the Dutch reference population, and tender joints, enthesitis at clinical examination, and back pain as indicators of pain affected HRQOL.

OBJECTIVE: . To compare the screening performance of the Psoriasis Epidemiology Screening Tool (PEST), Psoriatic Arthritis Screening and Evaluation (PASE) and Early Arthritis for Psoriatic Patients (EARP) questionnaires for detecting PsA among psoriasis patients in a primary care setting.METHODS: In a cross-sectional study, 473 primary care psoriasis patients at risk for PsA completed the PEST, PASE and EARP questionnaires and were clinically evaluated by a trained research nurse. A PsA case was defined by a rheumatologist according to the CASPAR criteria. Sensitivity and specificity were determined for the PEST and EARP cut-offs (⩾3) and the PASE cut-offs (⩾44 and ⩾47).RESULTS: PsA was diagnosed in 53 patients. The PEST had a sensitivity of 0.68 and a specificity of 0.71. The PASE was validated for two different cut-offs. The cut-off of 47 led to a sensitivity of 0.59 and a specificity of 0.66, whereas the lower cut-off of 44 led to a sensitivity of 0.66 and a specificity of 0.57. For the EARP we found a sensitivity of 0.87 with a specificity of 0.34.CONCLUSION: The PEST questionnaire has the most favourable trade-off between sensitivity and specificity to screen for PsA. However, as the prevalence of psoriasis and PsA is fairly low in primary care, screening only psoriasis patients with musculoskeletal complaints may be a better allocation of resources.

Background:Although the prevalence of Psoriatic Arthritis (PsA) is the same in men and women, women experience a higher burden of disease (pain, disability, fatigue) (1).The persistent belief that women tend to over-report their symptoms compared to men may also contribute to under or delayed diagnosis in women. The clinical pattern of PsA also differs, with men presenting more commonly with peripheral and axial joint damage and women being affected more frequently by polyarthritis (2). Furthermore, most disease activity measures contain pain and quality of life measurement metrics that may perform differently by sex. As a result, this may affect the clinician’s perception of disease severity, influence management decisions and subsequently introduce sex bias in prescribing.Objectives:To assess sex-related differences in baseline demographics, disease characteristics and evolution over 1 year in patients with newly diagnosed PsA.Methods:Our study is embedded in the Dutch south-west Early Psoriatic Arthritis prospective cohort study. We described patient characteristics using simple descriptive analysis techniques. For the comparison across sexes and baseline and 1 year follow up, appropriate tests depending on the distribution were used.Results:273 men and 294 women with no significant differences in age and ethnicity were included. Women reported significantly longer duration of symptoms before diagnosis and significantly fewer of them were in paid employment at baseline. Oligoarthritis was the most common pattern of arthritis in both sexes. Polyarthritis and enthesitis were more prevalent in women who also presented at baseline a significantly higher tender joint count (Fig.1) than men but no difference in swollen joint count.Figure 1.Longitudinal evolution of TJC68, Pain, VAS global, BRAF for men and women in the first year of PsA.All composite indices (CPDAI, DAPSA, GRACE, MDA, Psoriatic ArthritiS Disease Activity Score) showed significantly worse results in women at baseline. Women also suffered more frequently from comorbid medical conditions, fatigue and anxiety, and reported more severe limitations in function and worse quality of life.At 12 months women, despite the improvement they made, reported significantly higher levels of pain compared to men. Although MDA rates increase over time for both sexes,(Fig.2), it remained significantly more prevalent among men (19.0% vs 11.1% at inclusion,p, and 58.1% vs 35.7%,p, at T12). DAPSA was significantly higher in women at both timepoints and a significantly higher percentage of men presented remission according to DAPSA score at 12 months.Figure 2.Longitudinal evolution of composite measures for men and women in the first year of PsA.Conclusion:After 1 year of follow-up women didn’t surpass their baseline disadvantages and despite the improvement, they still present higher disease activity, more pain and lower functional capacity than men. The nature of these findings may advocate a need for sex specific adjustment of treatment strategies and evaluation in psoriatic arthritis as sex-related difference in outcome persisted over time.References:[1]Eder L, Thavaneswaran A, Chandran V, Gladman DD. Gender difference in disease expression, radiographic damage and disability among patients with psoriatic arthritis. Annals of the rheumatic diseases. 2013;72(4):578-82.[2]Orbai AM, Perin J, Gorlier C, Coates LC, Kiltz U, Leung YY, et al. Determinants of Patient-Reported Psoriatic Arthritis Impact of Disease: An Analysis of the Association with Gender in 458 Patients from 14 Countries. Arthritis care & research. 2019.Disclosure of Interests:Evangelia Passia: None declared, Marijn Vis Grant/research support from: Novartis, Pfizer – grant/research support, Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer – consultant, Laura C Coates: None declared, Anushka Soni Grant/research support from: Oxford-UCB prize fellowship, Speakers bureau: Janssen and Abbvie, Ilja Tchetverikov: None declared, Andreas Gerards: None declared, Lindy-Anne Korswagen: None declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Wiebo van der Graaff: None declared, Josien Veris-van Dieren: None declared, Natasja Denissen: None declared, F. Fodili: None declared, M. Starmans: None declared, Yvonne Goekoop-Ruiterman: None declared, M. van Oosterhout: None declared, Jolanda Luime: None declared

ObjectivesThe aim of this study is to evaluate the effectiveness of two tapering strategies after achieving controlled disease in patients with rheumatoid arthritis (RA), during 1 year of follow-up.MethodsIn this multicentre single-blinded (research nurses) randomised controlled trial, patients with RA were included who achieved controlled disease, defined as a Disease Activity Score (DAS) ≤ 2.4 and a Swollen Joint Count (SJC) ≤ 1, treated with both a conventional synthetic disease-modifying antirheumatic drugs (csDMARD) and a TNF inhibitor. Eligible patients were randomised into gradual tapering csDMARDs or TNF inhibitors. Medication was tapered if the RA was still under control, by cutting the dosage into half, a quarter and thereafter it was stopped. Primary outcome was proportion of patients with a disease flare, defined as DAS > 2.4 and/or SJC > 1. Secondary outcomes were DAS, European Quality of Life-5 Dimensions (EQ5D) and functional ability (Health Assessment Questionnaire Disability Index [HAQ-DI]) after 1 year and over time.ResultsA total of 189 patients were randomly assigned to tapering csDMARDs (n = 94) or tapering anti-TNF (n = 95). The cumulative flare rates in the csDMARD and anti-TNF tapering group were, respectively, 33 % (95% CI,24% to 43 %) and 43 % (95% CI, 33% to 53 % (p = 0.17). Mean DAS, HAQ-DI and EQ-5D did not differ between tapering groups after 1 year and over time.ConclusionUp to 9 months, flare rates of tapering csDMARDs or TNF inhibitors were similar. After 1 year, a non-significant difference was found of 10 % favouring csDMARD tapering. Tapering TNF inhibitors was, therefore, not superior to tapering csDMARDs. From a societal perspective, it would be sensible to taper the TNF inhibitor first, because of possible cost reductions and less long-term side effects.Trial registration numberNTR2754

Background: Methotrexate (MTX) is the preferred drug of most rheumatologists for treating psoriatic arthritis (PsA). Despite its widespread use in clinical practice, scientific evidence of methotrexate on the different manifestations of psoriatic disease is limited. Specifically, data of MTX use in usual care and in early PsA patients are lacking. Objectives: To describe the response to MTX for patients with PsA and an oligoarthritis or polyarthritis phenotype in usual care in the first year after diagnosis, and its impact on different aspects of the disease, including patients not achieving minimal disease activity (MDA) despite continuous exposure to MTX Methods: Data collected in the Dutch southwest Early Psoriatic Arthritis cohort (DEPAR) study were used. Patients with a new diagnosis of PsA who have not started disease-modifying antirheumatic drugs (DMARDs) for PsA were eligible to participate. In this analysis, only patients with a phenotype at time of diagnosis of oligoarthritis or polyarthritis (resp. 2-4 joints involved or 5 or more joints, as defined by the rheumatologist), and at least one year follow up were included. Research nurses collected clinical data and data on medication use every three months in the first year after diagnosis. The following outcomes were used to evaluate disease activity: MDA, EULAR active disease (at least one tender and swollen joint), disease activity index for PsA low disease activity (DAPSA-LDA: DAPSA≤14), and disease activity score 28 low disease activity (DAS28-LDA: DAS28≤3.2). Disease activity at six months of patients who started MTX within six months after diagnosis and have continued using MTX until one year after diagnosis was analyzed. Results: In April 2018, 219 patients had a phenotype of oligoarthritis (n=134, 61%) or polyarthritis (n=85, 39%) at time of diagnosis, and at least one year follow up. In 183 (84%) patients, MTX monotherapy was started within six months after diagnosis. Within the first year, 23 of these used MTX intermittently, 25 switched to a different DMARD, and 45 started a different DMARD while remaining on MTX therapy. The remaining 90 patients used MTX monotherapy throughout the first year and of these we assessed disease activity at 6 months after diagnosis. At 6 months, 38 patients out of these 90 were not in MDA despite continuous MTX treatment, while 44 achieved MDA. Major differences amongst the two groups included tender joint count, physical function, evaluation of pain and global disease activity and impact on health-related quality of life scores (Table 1). Conversely, 18% of all patients started MTX monotherapy were in sustained MDA at one year while continuing MTX monotherapy. Conclusion: The majority of patients with a new diagnosis of PsA with a phenotype of oligoarthritis or polyarthritis started MTX within a year after diagnosis. MTX is maintained as monotherapy in half of these patients, with 18% of them achieving sustained MDA using MTX monotherapy at one year. Interestingly, approximately half of the patients who had continued methotrexate monotherapy were not achieving MDA after six months and they report higher impact of disease on clinical and patient reported outcomes, suggesting need to consider improvement of therapy for these patients. Disclosure of Interests: Kim Wervers: None declared, Hannah den Braanker: None declared, Jolanda Luime: None declared, Ilja Tchetverikov: None declared, Andreas Gerards: None declared, Cathelijne Appels: None declared, Wiebo van der Graaff: None declared, Hans van Groenendael: None declared, Lindy-Anne Korswagen: None declared, Josien Veris-van Dieren: None declared, Johanna Hazes: None declared, Marc Kok: None declared, Marijn Vis Grant/research support from: Novartis

Objectives To compare responsiveness and longitudinal validity of Disease Activity Score 28 (DAS28), Disease Activity index for PSoriatic Arthritis (DAPSA), Composite Psoriatic Disease Activity Index (CPDAI), Psoriatic ArthritiS Disease Activity Score (PASDAS), GRAppa Composite scorE (GRACE) and Minimal Disease Activity (MDA) in usual care PsA patients, within 1 year after diagnosis. Methods Data collected in the Dutch southwest early PsA cohort (DEPAR) were used. Responsiveness was assessed using effect size (ES), standardized response mean (SRM), and discrimination between different general health states. Longitudinal validity was tested using mixed models with outcomes health-related quality of life (HRQOL), productivity and disability. Results Responsiveness was highest for PASDAS, with ES 1.00 and SRM 0.95, lowest for DAPSA, with ES 0.73 and SRM 0.71, and in between for DAS28, CPDAI and GRACE. Differences in general health were best discriminated with PASDAS and GRACE. Patients reporting stable or worsening general health could not be distinguished by DAS28 or CPDAI. Discrimination was better using DAPSA, but worse than when using PASDAS and GRACE. Longitudinal evolvement of HRQOL and productivity had the highest association with low disease activity according to GRACE, followed by PASDAS, MDA, DAPSA, DAS28, with the lowest association for CPDAI. Conclusion PASDAS and GRACE were superior with respect to responsiveness, and together with MDA best related to longitudinal evolvement of HRQOL, productivity and disability. Responsiveness and longitudinal validity of most outcomes were inferior for DAS28, DAPSA and CPDAI. As alternatives to the continuous measure DAPSA, use of PASDAS or GRACE should be considered.

Objective.Enthesitis is a manifestation of psoriatic arthritis (PsA), but its symptoms are difficult to interpret clinically. We investigated the associations of ultrasonographic changes in entheses with clinical characteristics in patients with PsA, and compared enthesis changes of patients aged 35 to 60 years with healthy volunteers of that age.Methods.Consecutive patients with PsA participated in this cross-sectional study, irrespective of enthesitis complaints and age. We collected data about complaints, physical activity and activity avoidance, medication, and clinical enthesitis. Inflammatory and structural enthesis changes were scored with the modified MAdrid Sonographic Enthesitis Index (MASEI). Among all patients, associations between ultrasound (US) scores and clinical characteristics were investigated using linear regression. We compared US scores of healthy volunteers and patients with PsA aged 35–60 years using Wilcoxon rank-sum tests.Results.Eighty-four patients with PsA and 25 healthy volunteers participated. In patients with PsA, we found a small association between higher inflammatory-modified MASEI score and older age (β 0.07, 95% CI 0–0.13) and current use of biologics (β 1.56, 95% CI 0.16–2.95). Patients who reported avoiding activities had significantly lower inflammatory-modified MASEI scores (β −1.71, 95% CI −3.1 to −0.32) than those who did not. The patients with PsA aged 35–60 years (n = 50) had similar inflammatory scores as healthy volunteers but higher structural scores (median 6 vs 2; p = 0.01).Conclusion.Within patients with PsA, avoiding physical activity, younger age, and not using biologics were associated with less enthesis inflammation. Patients with PsA and healthy volunteers aged 35 to 60 years displayed similar levels of inflammatory changes of the entheses, but patients had more structural damage.

Background:Rheumatologists play an important role in the management of patients with Psoriatic Arthritis (PsA). With PsA being a multifaceted disease, it can be challenging to assess the impact of psoriatic skin symptoms, next to the musculoskeletal complaints. We have previously shown that a dermatology-specific Health-related Quality of Life (HRQoL) questionnaire provides insight into the burden of skin symptoms, in contrast to a general HRQoL questionnaire.1 When treating PsA patients, specific questions on skin symptoms are necessary in order to assess the burden of psoriasis.Objectives:To create a set of questions that can easily identify PsA patients with a high psoriasis burden in daily rheumatology clinical practice.Methods:Data from patients receiving usual care were used from the Dutch south west Psoriatic Arthritis (DEPAR) cohort, consisting of newly diagnosed PsA patients included between July 2013 and March 2020. The two dermatology-specific HRQoL questionnaires used were the Skindex-17 and Dermatology Life Quality Index (DLQI), both with a one-week recall period.First, an exploratory principal component analysis (PCA) with varimax rotation was performed on both questionnaires combined, to identify underlying latent traits. Subsequently, items were dichotomized on their median frequencies. And a 2-parameter logistic (2PL) model was fitted for each latent trait. Item characteristic curves were plotted for each latent trait. Item selection took place based on the discrimination and difficulty of the items. Per latent trait, we selected 2 to 3 items distributed far apart across the latent trait. A flowchart was made with the selected questions.Results:In total, 413 patients with completed Skindex-17 and DLQI questionnaires at baseline were included. Mean (sd) age was 50.3 (13.4) years and median (IQR) Psoriasis Area and Severity Index (PASI) score 2 (0.5-4.2). The PCA gave the best fit with two underlying clusters of questions, namely psychosocial (n=20) questions and questions regarding physical symptoms (n=7). Three questions were selected to assess psychosocial impact and two for impact of physical symptoms (Figure 1). Questions should be asked in chronological order.Figure 1.Flowchart of questions assessing psoriasis burden.Cluster 1: PsychosocialThe first question is if the patient was embarrassed by their skin condition. If answered with “never”, the patient experienced the lowest burden. When answered with “rarely/sometimes” or “often/always”, continue to the second question. Ask the patient if they tended to stay at home because of their skin condition. If answered with “never”, they experienced a higher burden. If answered with “rarely/sometimes” or “often/always”, continue to the last question. Ask the patient if their skin condition has prevented them from working or studying. If not, the patient experienced a higher burden and if answered with “yes”, they experienced the highest burden in this domain.Cluster 2: Physical symptomsFirst ask the patient how itchy, sore, painful or stinging their skin was. If they answer with “not at all”, they experienced the lowest burden. If answered with “a little/a lot/very much”, continue to the second question. Ask if their skin was irritated. If answered with “never/rarely/sometimes”, they experienced a higher burden. If answered with “often/always”, the patient experienced the highest burden in this domain.Conclusion:We have created a practical guide for rheumatologists to distinguish PsA patients with a high psoriasis burden from those with a lower burden. With a minimum of two and a maximum of five questions, both psychosocial burden of psoriasis and burden of physical symptoms can be easily identified in daily clinical practice.References:[1]Kasiem FR, Kok MR, Tchetverikov I, Wervers K, Hazes J, Luime J, et al. AB0786 Impact of psoriasis severity on Health-Related Quality of Life in early psoriatic arthritis: results from real world data, the DEPAR study. Annals of the Rheumatic Diseases. 2020;79:1691-2.Disclosure of Interests:None declared

Background:The effect of inflammatory arthritis (IA) on fertility has been mainly studied in women. Multiple factors associated with lower fertility rate in women can also be present in male patients with IA (1). The fertility rate in men with IA, however, has never been studied.Objectives:To describe the fertility rate (number of biological children per individual) of men with IA.Methods:We performed a multicenter cross-sectional retrospective study conducted in eight Dutch hospitals. Men with IA (Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA) and Spondyloarthritis (SpA)) who were over 40 years old and indicated that their family size was complete were invited to participate. Men who were still planning on having biological children were excluded. Participants completed a digital questionnaire that included fertility-related questions and questions regarding their demographic and clinical information. To analyze the impact of IA on male fertility rate, patients were divided into groups according to the age at the time of their diagnosis: age41 years.Results:In total 628 participants diagnosed with IA were included. The response rate 34.87%. Information regarding their age, age at diagnosis, clinical diagnosis and number of children is presented per group in Table 1. Regarding the total number of children per man, there was a statistically significant difference between the three groups (p=41 years (1.88 {SD 1.14}). Compared to men from the general population of the Netherlands, the total number of children of men diagnosed at age>41 years was not statistically different (1.88 vs 1.80, respectively).Table 1.Participants’ basic demographic and clinical characteristics, including the number of biological children per men.All patientsIA diagnosed at age IA diagnosed at age 31-40 yearsIA diagnosed at age >41 yearsTotal, n (%)628137 (21.82)149 (23.73)342 (54.46)Age, mean (SD)57.17 (9.98)53.01 (9.96)52.76 (7.35)61.06 (9.47)Diagnosis, n (%)•iRA297 (47.29)42 (30.66)67 (44.97)188 (55.32)•AJIA10 (1.59)10 (6.25)0 (0)0 (0)•ISpA (incl. PsA)320 (50.96)90 (65.69)83 (55.70)147 (42.98)Age at diagnosis, mean (SD)41.29 (13.08)26.27 (9.15)36.99 (5.66)49.98 (9.70)Disease duration, mean (SD)15.89 (11.88)26.48 (12.57)15.70 (8.52)11.30 (9.87)Number of biological children, mean (95% CI)1.71 (1.60-1.81)1.39 (1.15-1.63)a,b1.60 (1.38-1.82)a1.88 (1.75 -2.01)a p< 0.05 compared to those diagnosed age >41 yearsb p< 0.05 compared to those diagnosed age >31-40 yearsConclusion:This is the largest study ever conducted to evaluate the impact of IA on male fertility. We demonstrated that men diagnosed with IA before and during their reproductive years have a lower fertility rate than those men diagnosed with IA after their reproductive years. Multiple mechanisms (biological and non-biological) can be responsible for this association. More research is needed to identify the causes of these lower fertility rates in men with IA.References:[1]Perez-Garcia LF, Te Winkel B, Carrizales JP, Bramer W, Vorstenbosch S, van Puijenbroek E, et al. Sexual function and reproduction can be impaired in men with rheumatic diseases: A systematic review. Semin Arthritis Rheum. 2020;50(3):557-73.Figure 1.Total number of biological children (mean and SD) per group.Acknowledgements:The authors would like to acknowledge Ron Buijs, data manager of the Department of Rheumatology of the Erasmus MC, for his technical support with regards to data collection.Disclosure of Interests:Luis Fernando Perez-Garcia Consultant of: Galapagos, Esther Röder: None declared, Robbert Goekoop: None declared, Johanna Hazes: None declared, Marc R Kok Consultant of: Novartis, Grant/research support from: Novartis, Petra Kok: None declared, Hieronymus TW Smeele: None declared, Ilja Tchetverikov: None declared, J.H. van der Kaap: None declared, Annette van der Helm - van Mil: None declared, Bouwe Krijthe: None declared, Radboud Dolhain Speakers bureau: UCB, Roche, Abbvie, Genzyme, Novartis, Consultant of: Galapagos, Grant/research support from: UCB

Background:The effect of inflammatory arthritis (IA) on pregnancy outcomes has been studied mainly in women. Paternal older age, sperm DNA integrity and certain genetic defects have been associated with worse pregnancy outcomes (1). However, pregnancy outcomes of partners of men with IA have never been studied.Objectives:To describe the pregnancy characteristics and outcomes of partners of men diagnosed with IA.Methods:We performed a multicenter cross-sectional retrospective study conducted in eight Dutch hospitals. Men with IA (Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA) and Spondyloarthritis (SpA)) who were over 40 years old and indicated that their family size was complete were invited to participate. Participants completed a digital questionnaire that included pregnancy-related questions and questions regarding their demographic and clinical information. To analyze the impact of IA on pregnancy outcomes, pregnancies were classified into two groups; pregnancies that occurred after diagnosis of IA and before the diagnosis of IA.Results:In total 628 male participants diagnosed with IA were included. 408 men reported 897 singleton pregnancies that resulted in 794 live births. Regarding pregnancy characteristics, pregnancies conceived after diagnosis of IA had a higher mean paternal and maternal age at conception and a lower rate of spontaneous pregnancies (90.91 vs 96.60%, p=Table 1.Pregnancy characteristics and outcomes.AllpregnanciesPregnancy afterdiagnosis of IAPregnancy before diagnosis of IAP valuePregnancy characteristicsTotal number of pregnancies897220677Maternal age at conception, mean (SD)29.00 (5.00)30.69 (5.16)28.45 (4.83)pPaternal age at conception, mean (SD)31.31 (5.72)34.27 (6.08)30.49 (5.34)pSpontaneous pregnancy, n (%)854 (95.21)200 (90.91)654 (96.60)pPregnancy duration-months, median (IQR)39 (38-40)39 (38-40)39 (38-40)p=0.928Pregnancy outcomesLive births, n (%)794 (88.52)190 (86.36)604 (89.22)p=0.053Miscarriage, n (%)78 (8.70)27 (12.27)51 (7.53)pAbortion, n (%)25 (2.78)3 (1.36)22 (3.25)p=0.128*Medical indication5 (20.00)0 (0)5 (22.73)*Personal reasons20 (80.00)3 (100.00)17 (77.27)Pre-term birth149 (16.61)31 (14.09)118 (17.43)p=0.248Pregnancy complicationsNo complications during pregnancy, n (%)754 (84.34)184 (83.64)570 (84.57)p=0.741Hypertensive disorders(hypertension, pre/eclampsia), n (%)41 (4.57)8 (3.64)33 (4.87)p=0.445Gestational Diabetes Mellitus11 (1.28)2 (0.94)9 (1.38)p=0.619Growth restriction12 (1.34)1 (0.45)11 (1.65)p=0.193Conclusion:This is the largest study to describe the pregnancy characteristics and outcomes of partners of men diagnosed with IA and the first to demonstrate that paternal IA is associated with a higher risk of miscarriage. Prospective studies are needed to corroborate these findings.References:[1]Ibrahim Y, Johnstone E. The male contribution to recurrent pregnancy loss. Translational andrology and urology. 2018;7(Suppl 3):S317-S27.Acknowledgements:The authors would like to acknowledge Ron Buijs, data manager of the Department of Rheumatology of the Erasmus MC, for his technical support with regards to data collection.Disclosure of Interests:Luis Fernando Perez-Garcia Consultant of: Galapagos, Esther Röder: None declared, Robbert Goekoop: None declared, Marc R Kok Consultant of: Roche, Grant/research support from: Roche, Petra Kok: None declared, Hieronymus TW Smeele: None declared, Ilja Tchetverikov: None declared, Annette van der Helm - van Mil: None declared, J.H. van der Kaap: None declared, Bouwe Krijthe: None declared, Radboud Dolhain Speakers bureau: Abbvie, UCB, Genzyme, Novartis, Consultant of: Galapagos, Grant/research support from: UCB

OBJECTIVES: With early and intensive treatment many patients with early RA attain remission. Aims were to investigate (1) the frequency and time to sustained remission and subsequent tapering in patients initially treated with conventional synthetic disease modifying anti-rheumatic drug ((cs)DMARD) strategies and (2) the frequency and time to flare and regained remission in patients tapering csDMARDs and biological (b)DMARDs during 2 years of follow-up.METHODS: Two-year follow-up data from the treatment in the Rotterdam Early Arthritis Cohort (tREACH) cohort were used. Patients were randomised to initial treatment with triple DMARD therapy (iTDT) with glucocorticoid (GC) bridging or methotrexate monotherapy (iMM) with GC bridging. Patients were evaluated every 3 months. In case Disease Activity Score (DAS) was >2.4 treatment was switched to a TNF-blocker. In case DASRESULTS: During 2 years of follow-up, sustained remission was achieved at least once by 159 (57%) of patients, of whom 118 and 23 patients initiated tapering of csDMARDs and bDMARDs, respectively. Thirty-four patients achieved drug-free remission. Flare rates were 41% and 37% and within 1 year, respectively. After flare, 65% of patients tapering csDMARDs re-achieved remission within 6 months after treatment intensification.CONCLUSIONS: Regardless of initial treatment strategy, 57% of patients achieved sustained remission during 2 years of follow-up. Flare rates were 41% and 37% within 12 months in patients tapering csDMARDs and bDMARDs, respectively.TRIAL REGISTRATION NUMBER: ISRCTN26791028; Post-results.

textabstractObjective To estimate the prevalence of psoriatic arthritis (PsA) in primary care patients diagnosed as having psoriasis and to estimate the prevalence of musculoskeletal symptoms in psoriasis patients in primary care. Methods We conducted a cross-sectional study in adult primary care patients with psoriasis. Responding patients reporting pain in joints, entheses, or the lower back were interviewed by telephone to determine eligibility and, if eligible, were invited for clinical evaluation. During clinical evaluation, skin, nails, joints, and entheses were assessed. Additionally, ultrasound of the enthesis was performed by an independent trained examiner if a patient had at least 1 tender enthesis (determined by the Leeds Enthesitis Index and the Maastricht Ankylosing Spondylitis Enthesitis Score). Patients who fulfilled the Classification of Psoriatic Arthritis (CASPAR) Study Group criteria were classified as having PsA. Results We invited 2,564 psoriasis patients from databases of 97 participating general practitioners. Of 1,673 responders (65.2%), 841 (50.3%) were willing to participate. A total of 823 patients (32.1%) reported having musculoskeletal symptoms; 659 of these patients were determined to be eligible, 524 of whom were clinically evaluated. We identified 64 cases of established PsA and another 17 cases of newly diagnosed PsA, leading to a prevalence of 3.2% (95% confidence interval [95% CI] 2.5-3.9) among psoriasis patients in primary care. This prevalence would increase to 4.6% (95% CI 3.8-5.4) if PsA cases based on enthesitis were also taken into account. Conclusion Among psoriasis patients in primary care, the prevalence of PsA is conservatively estimated to be 3.2%, increasing to 4.6% if enthesitis is taken into account. The prevalence of musculoskeletal symptoms among psoriasis patients is comparable with the prevalence of musculoskeletal symptoms in the general population.

Background:Oligoarthritis and polyarthritis are the predominant phenotypes in PsA. Previous we have shown that patients with oligoarthritis suffer a similar loss in quality of life as polyarthritis patients.1Although oligoarthritis is one of the most prevalent form, ample data is available on this phenotype.2-5Objectives:To evaluate the evolution of swollen joint count over the first year since diagnosis and to assess baseline difference in those groups that evolved differently over time.Methods:Our study is embedded in the Dutch south-west Early Psoriatic Arthritis (DEPAR) prospective cohort study. We described patient characteristics using simple descriptive analysis techniques. For the comparison across groups univariable multinomial logistic regression was used in STATA15. Oligoarticular disease was defined as 2, 3 or 4 swollen joints,Results:175 patients had a complete 12-month evaluation as of February 2019 (80% of all included patients with oligoarthritis). Baseline characteristics are shown in table 1. In total 63 percent of the patients (111/175) had resolution of swollen joints at 1 year. (figure 1). Over the first year, 27 patients had consistently no swollen joints since their 3 month evaluation, 26 had no swollen joint from 6 months and 12 from 9 months and 11 at 12 months. 65 of the 175 (37%) had inconsistently no swollen joints (intermittent) during the first year. In 8% of the patients values were missing to determine to which group they belonged. Univariable multinomial logistic regression of baseline characteristics showed that the group that had resolution of swollen joints ‘early’ (within 6 months) compared to (i) the group that ‘never’ had resolution differed in having fewer tender joints; (ii) the group having ‘late’ resolution of swollen joints (after 6 months) showed little difference and;(iii) the ‘intermittent’ group varied in smoking status, fatigue, being female and age. Multivariable analysis may reveal other patterns, but requires a larger sample than that currently available.Table 1.Baseline characteristics of oligo arthritis patients with complete follow-up at 1 year.n=175sex (% female)45%age51 (39-61)symptom duration (months)10.0BMI28 (24-32)current smoking23%paid employement70%(n=136)tender joint count3.0 (2.0-7.0)PASI2.0 (0.4-4.5)entheses44%dactylitis9%VASglobal42 (21-65)VASpain49 (25-68)HAQ0.63 (0.25-1.13)fatigue (BRAF)18 (10-30)Figure 1.Evolution of swollen joint count in psoriatic oligo arthritis (n=175) over time expressed in a binary swollen joint count (yes: 0 / no: sjc!==0; mv= missing value),Conclusion:In our set of real world data, about one third of the PsA patients with oligoarticular disease had no resolution of swollen joints at 1 year. About half of these patient had consistently inflamed joints over time. Another third of the PsA patients had intermittently inflamed joints. At baseline these groups seems comparable in clinical presentation, demographics and PROMs, although some variation existed between early versus never and early versus intermittent resolution of swollen joints. Both indices provide room for improvement in the management of oligoarticular disease in PsA.References:[1]Wervers K et al. 2018 Nov;45(11):1526-1531[2]Jones SM, et al. Br J Rheumatol. 1994;33(9):834-9[3]Dönmez S, et al Clin Rheumatol. 2015;34(6):1091-6[4]Iannone F, et al Scand J Rheumatol. 2015;44(3):192-9[5]Kruithof E, et al Arthritis Res Ther. 2005;7(3):R569-80Disclosure of Interests:Marijn Vis Grant/research support from: Novartis, Pfizer – grant/research support, Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer – consultant, Kok Marc Grant/research support from: Novartis, Pfizer, Celgene, Lilly, UCB, Consultant of: Novartis, Celgene, Speakers bureau: Celgene, Ilja Tchetverikov: None declared, Johanna Hazes: None declared, Jolanda Luime: None declared

Background:Psoriasis is an important feature of psoriatic arthritis (PsA). Psoriasis itself is known to have a significant impact on Health-related Quality of life (HRQoL)1, however its role within PsA is less well understood. In daily practice, assessment of psoriasis may not always be a priority for rheumatologists, having been trained to focus on articular involvement. In order to assess whether psoriasis deserves more attention from rheumatologists, the aim of this study is to evaluate the influence of psoriasis on HRQoL in early PsA patients.Objectives:To describe the evolution of psoriasis severity during the first year of follow up in patients with early PsA and to evaluate the impact of psoriasis severity on HRQoL.Methods:Real world data were used from the Dutch south west Psoriatic Arthritis cohort (DEPAR) study, consisting of newly diagnosed PsA patients included between July 2013 and February 2019. Psoriasis severity was assessed using the Psoriasis Area and Severity Index (PASI) and categorized in: no psoriasis (PASI 0), mild psoriasis (PASI12). Musculoskeletal disease severity was measured with the Disease Activity in PSoriatic Arthritis (DAPSA) score as contrast for psoriasis severity. DAPSA was categorized in: remission (REM[DAPSA≤4]), low disease activity (LDA[DAPSA≤14]), moderate disease activity (MDA[DAPSA≤28]) and high disease activity (HDA[DAPSA>28]).2General HRQoL was assesed with the Short-Form 36 (SF-36[Physical component scale and Mental component scale]). Skin-specific HRQoL was measured with the Skindex-17 (psychosocial scale and symptoms scale).Results:In total, 435 patients were included. Mean (sd) age was 49.7 (13.4) years and 53% (n=229) was male. Psoriasis severity does not fluctuate much over the course of the first year and the majority of patients had mild psoriasis (Figure 1). HRQoL worsened with increasing psoriasis severity, when measured by the Skindex17. This reduction in HRQoL was not seen when measured with the SF-36 (Figure 2).Figure 1.Psoriasis severity categories during the first year of follow up. No psoriasis (PASI 0), mild psoriasis (PASI12).Figure 2.A, B: Median Skindex17 psychosocial score and symptoms score per psoriasis severity category and DAPSA category at baseline. C,D: Mean SF36 Physical component scale (PCS) score and Mental component scale (MCS) score per psoriasis severity category and DAPSA category at baseline. No psoriasis (PASI 0), mild psoriasis (PASI12). REM (DAPSA28)Conclusion:In early PsA patients, psoriasis severity is mostly mild, but considerably impacts HRQoL when measured using a skin specific questionnaire. For optimal management of PsA patients, we therefore recommend rheumatologists to additionally acquire information on the degree of psoriatic involvement. In our opinion, this information is valuable for the adequate assessment of HRQoL.References:[1]Strober B, Greenberg JD, Karki C, Mason M, Guo N, Hur P, et al. Impact of psoriasis severity on patient-reported clinical symptoms, health-related quality of life and work productivity among US patients: real-world data from the Corrona Psoriasis Registry. BMJ Open. 2019;9(4):e027535.[2]Schoels MM, Aletaha D, Alasti F, Smolen JS. Disease activity in psoriatic arthritis (PsA): defining remission and treatment success using the DAPSA score. Ann Rheum Dis. 2016;75(5):811-8.Disclosure of Interests:Fazira R. Kasiem: None declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Ilja Tchetverikov: None declared, Kim Wervers: None declared, Johanna Hazes: None declared, Jolanda Luime: None declared, Marijn Vis Grant/research support from: Novartis, Pfizer – grant/research support, Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer – consultant

Background Treat-to-target strategies have improved outcomes in rheumatic diseases. In psoriatic arthritis (PsA), the proposed targets are the multidimensional target Minimal Disease Activity (MDA) and the articular target Disease Activity index for PsA (DAPSA). Objectives We aimed to compare burden of PsA in patients with low disease activity according to the two definitions MDA and DAPSA-Low Disease Activity (DAPSA-LDA), one year after diagnosis. Methods We obtained data on MDA, DAPSA-LDA and disease burden one year after diagnosis from patients included in the Dutch southwest early PsA cohort. Disease burden was assessed in two domains: ‘Body Functions’, including Short Form 36 Bodily Pain (SF36-BP), and ‘Activity’, including Health Assessment Questionnaire (HAQ). Results Of the 292 patients included, 48% achieved MDA and 64% DAPSA-LDA. Average ‘Body Functions’ and ‘Activity’ were similar in patients in MDA and patients in DAPSA-LDA. However the scores were significantly better in the 44% of patients in both MDA and DAPSA-LDA than in the 20% of patients only in DAPSA-LDA. The average SF36-BP was higher in patients achieving both targets (74.7, 95% CI 72.0–77.4) than in patients only in DAPSA-LDA (58.7, 95% CI 54.8–62.6). Similarly, mean HAQ scores measuring ‘Activity’ were 0.19 (95%CI 0.14–0.25) and 0.61 (95%CI 0.48–0.73) respectively. Conclusions Of patients newly diagnosed with PsA, 48% achieved MDA and 64% DAPSA-LDA after one year receiving usual care. Average disease burden was similar in patients in MDA and in patients in DAPSA-LDA. However, those that only achieved DAPSA-LDA reported worse outcomes than those also achieving MDA. Disclosure of Interest None declared

Objectives: To investigate whether, apart from effects of patient- and disease-related factors, psychosocial factors have additional effects on disease activity; and which factors are most influential during the first year of treatment in early rheumatoid arthritis (RA). Method: The study assessed 15 month follow-up data from patients in tREACH, a randomized clinical trial comparing initial triple disease-modifying anti-rheumatic drug therapy to methotrexate monotherapy, with glucocorticoid bridging in both groups. Patients were evaluated every 3 months and treated to target. Associations between Disease Activity Score (DAS) at 3, 9, and 15 months and psychosocial factors (anxiety, depression, fatigue, and coping with pain) at the previous visit were assessed by multivariable linear regression correcting for demographic, clinical, and treatment-related factors. Results: At 3, 9, and 15 months of follow-up, 265, 251, and 162 patients, respectively, were available for analysis. Baseline anxiety and coping with pain were associated with DAS at 3 months; coping with pain at 6 months was associated with DAS at 9 months, and fatigue at 12 months with DAS at 15 months. Psychosocial factors were moderately correlated. Effects on DAS were mainly due to tender joint count and global health. Conclusion: Psychosocial factors have additional effects on DAS throughout the first year of treatment in early RA. A change was observed from anxiety and coping with pain at baseline being associated with subsequent DAS towards fatigue being associated with subsequent DAS at 12 months. Owing to the explorative nature of this study, more research is needed to confirm this pattern.

OBJECTIVES: Although RA patients achieve clinical remission, risk of flare still exists. Given the association between US synovitis and increased risk of flare, it is of clinical interest whether these patients report a different health status. Therefore, our aim was to evaluate the frequency of US remission in RA patients in clinical remission and to compare the health status of RA patients in clinical remission with those who were also in US remission.METHODS: In a prospective study, we included 89 RA patients (aged >17 years) treated with a synthetic DMARD and a TNF inhibitor who were in remission (DAS in 44 joints ⩽2.4 and swollen joint count ⩽1). Demographic characteristics, swollen and tender joints, laboratory variables, US (MCP2-5, PIP2-5, wrists and MTP2-5) and patient-reported outcomes (general health, functional ability, fatigue, depression and anxiety, pain and morning stiffness) were recorded at two consecutive visits (3 months apart). US remission was defined as grey scale grade ⩽1 and power Doppler = 0.RESULTS: At visit 1, 39% of patients were in US remission. At visit 2, 32% of patients were in US remission. At visit 1, functional ability (HAQ) was scored lower by patients in US remission (P = 0.029). At visit 2, HAQ scores were similar (P = 0.928). At visit 2, Hospital Anxiety and Depression Scale anxiety score and visual analog scale pain were significantly higher in patients in US remission. Similar levels were found for the other patient-reported outcomes.CONCLUSION: One-third of RA patients in clinical remission were in US remission. In our study population, we could not find a clear association between health status of RA patients and being in US remission.

Background A substantial amount of young patients with chronic low back pain (CLBP) have axial spondyloarthritis (axSpA), but early recognition of these patients is difficult for general practitioners (GPs). Recently, the CaFaSpA referral rule has been published and externally validated. It is an easy to use referral strategy that has shown to be able to identify patients with CLBP at high risk for axSpA in a primary care setting. The CaFaSpA referral rule consists of 4 items: inflammatory back pain, family history of axSpA or related disease, good reaction to NSAIDs and duration of back pain ≥5 years. If at least 2 out of 4 items are present, the referral rule is positive and a referral to a rheumatologist is advised. Objectives To assess the effect of the CaFaSpA referral rule on disability in young CBPP patients by comparing it with usual care, using the format of an impact analysis. Methods A cluster randomized controlled trial with GP practices as clusters. GP practices were randomized to either the intervention (use of the referral strategy) or control (usual care) group. Within these GP practices, patients aged 18–45 years with current CLBP were recruited. The primary outcome was disability caused by low back pain, measured with the Roland Morris Disability Questionnaire (RMDQ) scale 0–24. RMDQ score was obtained at baseline and 4 months after a referral advice was made. A higher RMDQ score means more disability. For statistical analysis a linear mixed effects regression model was used. Results 92 primary care practices were randomized, 679 patients participated (64% women, mean age 36.2 years (SD7.5) and median CLBP duration 9 years (IQR 4–15 years). 333 patients were randomized to the intervention group, both groups had similar characteristics at baseline. Sixty percent of participants had a positive referral rule. RMDQ scores are shown in table 1. Sub scores are shown for patients with a positive outcome of the referral rule (PRR) and a negative outcome of the referral rule (NRR). The change in RMDQ score after 4 months in the intervention group was -0.74 (95% confidence interval (CI) -1.31 – -0.18) and in the control group -0.46 (95% CI -0.98 – 0.05). There was no significant difference between groups. Conclusions Compared with usual care, use of the CaFaSpA referral rule in CLBP patients in a primary care setting did not significantly impact disability in these patients, 4 months after a referral advice was made. Results after 12 and 24 months should be awaited before definitive conclusions about the impact of the CaFaSpA referral rule for axSpA in CLBP patients can be made. Disclosure of Interest None declared

Background The Psoriatic Arthritis Impact of Disease 12-item questionnaire (PsAID12) has been developed to measure impact of Psoriatic Arthritis (PsA) for purposes of monitoring and clinical management. Although validated in patients with longstanding disease, data on validity and sensitivity to change in early PsA is lacking. Objectives We aim to relate change in disease activity to change in PsAID12 score in early PsA and evaluate which PsAID domains are more likely to change. Methods Patients with a new diagnosis of PsA were included in the Dutch southwest Early Psoriatic Arthritis cohoRt (DEPAR). For this analysis, patients that have PsAID12 (range 0–10) and Composite Psoriatic Disease Activity Index (CPDAI, range 0–15) data at two consecutive visits (i.e. 3 months apart) within the first year were included. In case multiple periods per patients were available, the first time period was chosen. The change in PsAID is compared to the change in disease activity over this period, measured with the CPDAI using Spearman9s correlation coefficient. Change in score on individual domains of the PsAID was analysed in subgroups of patients that perceived improvement in health and those that perceived worsening. The SF-36 question on self-perceived change in health was used to determine these subgroups. Results 143 unique patients had at least one period with two PsAID and CPDAI measurements (67 from baseline-3 months, 26 3–6 months, 25 6- 9 months and 25 9–12 months). Mean age was 51 (SD 13.7) and 70 (49%) were male. The initial median PsAID was 3.35 (IQR 1.4–5.1) and the subsequent score was 2.25 (0.95–4.8 with a mean delta of 0.52 (P Conclusions Improvement in CPDAI disease activity is significantly but moderately associated with improvement in PsAID score, with the biggest improvement in the pain domain in patients with a self-reported improvement of health. Disclosure of Interest None declared

Background Previous research in our group showed that sonographic signs of enthesitis are present in early and established PsA, but in young healthy volunteers as well. The Madrid Sonographic Enthesitis Index (MASEI) was only able to differentiate between patients and healthy volunteers after excluding knee enthesis thickness from the score and semi-quantitative scoring of Power Doppler (PD) signal (1). Objectives We aim to validate the modified MASEI in a larger cohort of established PsA patients and healthy volunteers. Methods Established PsA patients and healthy volunteers aged 35–55 were asked to participate in this cross-sectional study, irrespective of presence of enthesitis complaints. The triceps, quadriceps, proximal and distal patellar and Achilles tendon and plantar fascia (i.e. the locations of the MASEI) and the common extensor insertion at the lateral epicondyle of the elbow were evaluated sonographically for structural changes (i.e. erosions, calcifications and structure) and active inflammation (thickness, bursitis and PD). Results 84 established PsA patients and 25 healthy volunteers participated. Sonographic structural changes and one or two spots of PD signal were common in both groups. The modified MASEI was significantly higher in PsA patients (median 12 (IQR 7.25–17) vs. 7.5 (5–9), P Conclusions Inflammatory and structural changes of the enthesis measured with ultrasound are common in both unselected PsA patients and healthy volunteers, but more pronounced in established PsA patients. References Wervers K, Rasappu N, Vis M, Tchetverikov I, Kok MR, Gerards AH, et al. AB0733 Masei Shows Substantial Changes in The Entheses of Young Healthy Volunteers – Amending Its PD Score and Excluding Knee Entheses Thickness Provides Better Discrimination of Enthesitis in Psoriatic Arthritis Patients. Ann Rheum Dis 2016;75:1155. Disclosure of Interest None declared

Background Psoriatic arthritis (PsA) is a multifaceted disease. Objectives We aimed to evaluate change in medication over time guided by joints, skin, enthesis, low back pain and dactylitis in newly diagnosed PsA patients Methods Newly diagnosed PsA patients were included in the Dutch Early south-west Psoriatic Arthritis cohoRt (DEPAR) study between August 2013 and March 2016. Initial drug treatment and escalation of therapy were described for all patients. Drivers of treatment changes in the first year were evaluated by mixed ordered ordinal regression with outcome treatment change and variables joints (66/68 count), skin (PASI), entheses (LEI and MASES), dactylitis (LDI) and axial disease (BASDAI) Results 323 patients had had baseline assessment in March 2016. Their average age was 50.0 years (SD 13.8) and 49% were male. 80% patients had arthritis (19% monoarthritis, 39% oligoarthritis and 23%polyarthritis), 9% had an enthesitis subtype, 2% axial disease and 9% dactylitis. Initial treatment consisted of methotrexate (MTX) (52%), in 7% of other synthetic disease modifying antirheumatic drugs (sDMARDs) and due to treatment of psoriasis 3% biologicals. Within the different phenotypes MTX was most frequently started in polyarthritis (84%) followed by oligoarthritis (63%), monoarthritis (33%) and other phenotypes (5%). At 12 months 70% (n=148) stayed on the initial drug. Of those switched, 9 started MTX, within the initial MTX users (n=74) almost equal percentages stopped, switched to metoject or biological (4%). A smaller percentage (2%) switch to leflunomide. Changes in medication were driven by swollen joint count and the presence of dactylitis (Table 1) Conclusions MTX was initiated in about half of the early PsA patients. The majority of patients were kept on the initial treatment strategy in first year. Failure on initial drug led to variation in subsequent drugs with additional start of other sdmards, switch subcutaneuous MTX, to other sdmards or to biological dmards. Treatment change was driven by Swollen Joint Count and presence of Dactylitis. Skin, Enthesis and Axial disease did not play a role in escalating treatment. Disclosure of Interest None declared

Background In Psoriatic arthritis (PsA) the pattern of joint involvement seems to be more heterogenic than Rheumatoid Arthritis (RA). Therefor the 66/68 joint count is frequently used in PsA scores. In this study we would like to investigate whether using less extensive joint counts influences PsA disease activity measures Objectives To evaluate the effect of using a 28, 44 or 66/68 joint count on Minimal Disease Activity (MDA). Methods Newly diagnosed PsA patients were included in the Dutch Early south-west Psoriatic Arthritis Registry (DEPAR) study between August 2013 and January 2017. Joint scores at baseline and 6 months were calculated using a 28, 44 and 66/68 joint count. Consecutively MDA was calculated using each of these joint counts. MDA is defined as minimal disease activity in 5 out of 7 domains (swollen joints, tender joints, PASI, patient vas pain, patient vas global, HAQ, enthesitis) Results In total, 413 patients were included into the study, of which 320 had reached 6 months follow-up at the time of this abstract. Half of the patients were male (49%), and mean age was 50 years (SD 13.8). The percentage of patients with at least one involved joint (swollen or tender) at baseline decreased from 91% using the 66/68 score to 88% with 44 joints and then to 80% with a 28 joint count (Table 1). At 6 month these scores were 66% 63% and finally 56% respectively for the 66/68, 44 and 28 joint count. After 6 months, 96 patients (30%) had achieved MDA using the original 66/68 joint count. Using a 28 joint count, 10 more patients (10% of the MDA population) were classified as having achieved MDA. Conclusions Using reduced joint count joints in PsA misclassifies around 10% of patients as having no joint involvement. It also misclassifies about 10% of the MDA population of having achieved MDA while they have not. Full 66/68 joint counts remain recommended for measuring disease activity in PsA. Disclosure of Interest None declared

Background Enthesitis is one of the manifestations of psoriatic arthritis (PsA), but no clear definition for the diagnosis exists. To further evaluate the added value of sonographic evaluation of entheses in diagnosing enthesitis, more knowledge on factors associated with sonographic enthesitis is needed. Objectives We aim to evaluate which clinical characteristics are associated with sonographic enthesitis changes in a cross-sectional PsA population. Methods established PsA patients were asked to participate, irrespective of enthesitis complaints. Patients were interviewed on history of musculoskeletal complaints (MSC), more specifically if they had complaints during activities and whether they avoided physical activities (during exercise, work, household tasks, hobbies, chores). Tenderness was determined in the MASEI entheses and those in the Leeds Enthesitis Index (LEI) and Maastricht Ankylosing Spondylitis Enthesitis Score (MASES). Previously we showed that a modified Madrid Sonographic Enthesitis Index (MASEI, i.e. excluding knee enthesis thickness and scoring PD-signal semi-quantitatively) distinguishes entheses of PsA patients from those of healthy volunteers (1). A sonographist unaware of clinical findings scored the modified MASEI. Multivariable linear regressions of structural (erosions, calcifications, structure) and inflammatory (thickness, bursitis and PD) modified MASEI scores were performed (transformed for a better distribution). Variables included age, gender, PsA duration, medication use (non/nsaids vs. sDMARDs vs. bDMARDs), LEI + MASES and avoidance (no vs. yes). Results 84 PsA patients participated (45 males, mean age 55, median disease duration 8 years). Median modified MASEI was 12 (IQR 7.25–17), with a structural component score of 7 (3–10) and inflammatory component score of 6 (3.5–8.5). 8 patients used no medication or NSAIDs only, 36 used sDMARDs and 40 used bDMARDs. 45 patients reported avoiding activities. In a multivariable analysis, inflammatory modified MASEI was negatively associated with avoidance (i.e. fewer inflammatory changes in patients reporting avoidance) and positively associated with age, BMI and use of biologics. Structural MASEI was positively associated with age only. Conclusions Avoiding physical activities is associated with fewer inflammatory changes of the entheses. More inflammatory changes are seen in older or overweight patients and patients on biologicals, in the latter possibly due to more active disease. References Wervers K, Rasappu N, Vis M, Tchetverikov I, Kok MR, Gerards AH, et al. AB0733 Masei Shows Substantial Changes in The Entheses of Young Healthy Volunteers – Amending Its PD Score and Excluding Knee Entheses Thickness Provides Better Discrimination of Enthesitis in Psoriatic Arthritis Patients. Ann Rheum Dis 2016;75:1155. Disclosure of Interest None declared

A 25-year-old man was admitted to our hospital, with fever, severe ulceration of the oral and pharyngeal mucosa, and pustules on his skin. These pathergy-like lesions had emerged after placement of orthodontic braces and laser therapy for hair removal, respectively. The patient's clinical condition, together with his ethnic background, pointed to the diagnosis of Behcet's disease. Treatment with colchicine and prednisone resulted in rapid improvement of his symptoms. Pathergy reactions in response to placement of dental braces and laser hair removal are a rare first presentation of Behcet's disease.

Part of the psoriasis patients with musculoskeletal complaints will have inflammation of the entheses. Entheseal inflammation is difficult to assess by clinical examination only. Therefore, we aimed to determine the frequency of clinically relevant ultrasound inflammation at the most commonly assessed entheses (MASEI; Madrid Sonographic Enthesis Index) in primary care psoriasis patients with one or more tender entheses.Adult primary care psoriasis patients with musculoskeletal complaints (tender enthesis or arthritis at physical examination) had an ultrasound examination of seven entheses according to the MASEI. Clinically relevant ultrasound inflammation was defined as active inflammation on ultrasound in combination with at least one clinical feature at the same enthesis. Active ultrasound inflammation contained positive power Doppler signal or in case of the plantar aponeurosis increased thickness. Structural changes entailed calcifications, enthesophytes, increased thickness, hypoechogeneicity indicating irregular fibre structure and erosions. Clinically, an enthesis was scored positive by a tender enthesis at clinical examination, reported pain in the history or self-reported pain in the questionnaires.Of 542 primary care psoriasis patient, 111 patients had tender entheses and/or arthritis. These patients were both clinically and ultrasonographically evaluated. Active ultrasound inflammation accompanied with pain or tenderness at the enthesis was found in 36% of the patients (n=40). Most common were inflammation at the knee (n=11) and at the plantar aponeurosis (n=10). Structural changes were observed in 95% of the psoriasis patients independent of their clinical manifestation.We found concurrent presence of ultrasound inflammatory changes and clinical symptoms in 36% of the primary care psoriasis patients who had tenderness at one or more entheseal sites.

To estimate the prevalence of psoriatic arthritis (PsA) in primary care patients diagnosed as having psoriasis and to estimate the prevalence of musculoskeletal symptoms in psoriasis patients in primary care.We conducted a cross-sectional study in adult primary care patients with psoriasis. Responding patients reporting pain in joints, entheses, or the lower back were interviewed by telephone to determine eligibility and, if eligible, were invited for clinical evaluation. During clinical evaluation, skin, nails, joints, and entheses were assessed. Additionally, ultrasound of the enthesis was performed by an independent trained examiner if a patient had at least 1 tender enthesis (determined by the Leeds Enthesitis Index and the Maastricht Ankylosing Spondylitis Enthesitis Score). Patients who fulfilled the Classification of Psoriatic Arthritis (CASPAR) Study Group criteria were classified as having PsA.We invited 2,564 psoriasis patients from databases of 97 participating general practitioners. Of 1,673 responders (65.2%), 841 (50.3%) were willing to participate. A total of 823 patients (32.1%) reported having musculoskeletal symptoms; 659 of these patients were determined to be eligible, 524 of whom were clinically evaluated. We identified 64 cases of established PsA and another 17 cases of newly diagnosed PsA, leading to a prevalence of 3.2% (95% confidence interval [95% CI] 2.5-3.9) among psoriasis patients in primary care. This prevalence would increase to 4.6% (95% CI 3.8-5.4) if PsA cases based on enthesitis were also taken into account.Among psoriasis patients in primary care, the prevalence of PsA is conservatively estimated to be 3.2%, increasing to 4.6% if enthesitis is taken into account. The prevalence of musculoskeletal symptoms among psoriasis patients is comparable with the prevalence of musculoskeletal symptoms in the general population.

Measurement of serum angiotensin-converting enzyme (ACE) activity can be helpful in the diagnosis and disease monitoring of sarcoidosis. Elevated serum ACE activity is found in 60–70% of sarcoidosis patients. Usually, the ACE activity is mildly increased (

Background Various screening tools have been developed and validated over the years in order to enhance early recognition of psoriatic arthritis (PsA) among psoriasis patients, but their performance remains suboptimal. In 2014 the CONTEST-group developed a new screening tool consisting of the most discriminating questions from 3 existing tools (PEST, PASE, TOPAS) which was externally validated in 2 psoriasis cohorts from dermatology. Validation in a primary care setting has yet to be performed. Objectives To externally validate the CONTEST questionnaire in psoriasis patients in primary care. Methods Data from the SENSOR study was used, a cross-sectional study in adult psoriasis patients with regular spells of musculoskeletal complaints from primary care. In this study, patients completed the PEST and PASE screening-questionnaires before clinical evaluation. Within CONTEST 3 TOPAS questions are used that were not included in our study. These questions were therefore replaced by similar questions: ToPAS 2A was replaced by PEST 3, ToPAS 2B by nail assessment by a dermatologist and ToPAS 7 by data from the manikin in the PEST. We calculated sensitivity, specificity and area under the curve (AUC) for the CONTEST with a cutoff of 4, as well as the CONTEST-w (weighted version, cutoff of 8) and the CONTEST-jt (including the PEST manikin, cutoff of 5). Performance was also calculated selecting the patients in the same way as the CONTEST study, i.e. only inviting patients with a positive PEST and/or PASE questionnaire for clinical evaluation. As a reference standard we used a clinical diagnosis of PsA made by a rheumatologist and enthesitis confirmed by ultrasound (presence of Power Doppler). Results from our dataset were compared with data from the development cohort and with the performance of the PEST. Results For this analysis 473 psoriasis patients at risk for PsA were available. Compared with the development cohort sensitivity was considerably lower in our dataset (0.30–0.51) than in the development of the CONTEST (0.86). Specificity was higher in our dataset (0.75–0.87) compared with the CONTEST development (0.35–0.48). While AUCs were around 0.7 for all three versions, comparable with the AUCs found in the development of CONTEST. Comparing these results with the performance of the PEST in our population, it shows that the sensitivity is lower for the CONTEST (0.30–0.51) than for the PEST (0.68), while the specificity is slightly higher (0.75–0.87 vs 0.71). Conclusions External validation of the CONTEST questionnaire in primary care psoriasis patients with regular spells of musculoskeletal symptoms resulted in lower sensitivity and higher specificity compared to the development cohort, while AUCs were comparable. When only selecting patients with at least one positive screeningtool, the sensitivity slightly increases while the specificity slightly decreases. However, the performance of the CONTEST questionnaires does not seem to exceed the performance of the PEST in a primary care setting. Acknowledgement This study was financially funded by an investigator-initiated grant from Pfizer bv. Disclosure of Interest None declared

Background Psoriatic arthritis (PsA) is a disease with musculoskeletal and skin inflammation (psoriasis). Attempts are being made to develop comprehensive disease measures to capture global disease activity. However very little is known on how much psoriasis actually affects quality of life (QOL) in patients with PsA. Objectives In this study we aim to determine to what extent psoriasis affects quality of life in incident Psoriatic Arthritis patients. Methods Data collected at baseline in the Dutch south west Psoriatic Arthritis Registry (DEPAR) study were used. The DEPAR includes newly diagnosed PsA patients from 8 hospitals in the South-West of the Netherlands. PsA core measurements were collected: Swollen and Tender join count (66/68), enthesitis (LEI and MASES), dactylitis (LDI) and psoriasis (PASI). In addition 3 patient reported measures of quality of life were administered. Short Form-36 (SF-36) is a self-administered 36-item health survey questionnaire. The items are assigned to eight scales grouped in two factors: physical component summary (PCS) and mental component summary (MCS, score 0–100). Skindex-17 is a self-administered 17-item dermatology questionnaire that explores functioning, emotions and symptoms in a Symptoms Subscale (SS; range 0–10) and a Psychosocial Subscale (PS; range 0–24).The DLQI is a self-administered 10-item questionnaire, score 0–30 with higher scores resulting in poorer quality of life. It covers Symptoms and feelings, Daily activities, Leisure, Work and school, Personal relationships and Treatment Results In total 281 patients were included: mean age was 50.6 (SD 13.6) and 50.5% were male. In terms of arthritis subtypes, 56 (20%) had mono-arthritis, 108 (39%) oligo-arthritis, 80 (29%) poly-arthritis and 35 (12%) were diagnosed with axial disease, dactylitis or enthesitis only. The Median PASI score was 2.3, ranging from 0 to 22.5. Divided in PASI categories (1) this resulted for 12% in no skin disease, 72% mild (>0–7), 11% moderate (7–12) and 5% had severe (>12) psoriasis. Median PASI scores were different for mono, oligo to polyarthritis group: 2.7 (0–12.3), 3.4 (0–22.5) and 4.4 (0–21). Skin related quality of life measured by DLQI showed a median 1 (QR 0–5) and the two subscales of the skindex resulted in a median SS 4 (IQR 2–6) and a PS of 2 (IQR 0–8), and a SF-36 PCS of 40.3 (8.3) and SF-36 MCS of 47.7 (10.4).(table 1) Comparing none and mild psoriasis to moderate and sever psoriasis resulted in median scores for DLQI: 1 vs 5 (p Conclusions Skin involvement in incident Psoriatic Arthritis is in the majority of patients mild with median PASI score of 2.3. About 15% suffered from moderate to severe psoriasis. Skin quality of life measures showed poorer health states for these patients, which was also reflected in the emotional role and bodily pain subscale of more generic QOL questionnaire: SF-36. Disclosure of Interest None declared

Background Tendon complaints are common in both healthy adults and patients with psoriatic arthritis (PsA). Ultrasound (US) could be used to investigate whether these are located at the enthesis and of inflammatory origin, as it is able to detect structural changes and inflammatory changes using Power Doppler. Objectives We aim to describe the difference in ultrasound abnormalities in the entheses of patients with recently diagnosed PsA, patients with established PsA and young healthy volunteers (20–30 years). using the MASEI US score Methods Consecutively newly diagnosed PsA patients participating in the Dutch south west Psoriatic Arthritis Registry (DEPAR), patients with >2 years PsA and healthy volunteers (aged 20–30 years) were asked to participate. An ultrasound was performed by one examiner unaware of clinical findings using an Esoate Mylab 60 (probe LA-435 and LA-523). The triceps, quadriceps, proximal and distal patellar and Achilles tendon insertion, plantar fascia (i.e. the locations of the Madrid Sonographic Enthesis Index; MASEI) and the tendon insertion at the lateral epicondyle of the elbow were investigated (1). In each location structural changes, erosions, calcifications, increased thickness and Power Doppler signal and is some locations bursitis were evaluated, resulting in a total score (range 0–158). Results In total, 25 newly diagnosed PsA patients (A), 25 established PsA patients (B) and 25 healthy volunteers (C) participated. The median of the MASEI+ score was for A 18 (IQR 15–30), for B 22 (IQR 15–27) and for C 10 (IQR 5–15) (Table 1). Of note, the reference values for thickness of the Quadriceps tendon at the superior pole (6.1 mm), the inferior pole (4.0 mm) and the insertion at the tuberosity of the tibia (4.0 mm) were exceeded by 50%, 58% and 70% of the entheses of healthy volunteers (50 tendons). Also the degree of Power Doppler signal varied from one spot of signal to a confluent signal in large section of the enthesis, suggesting different levels of inflammation or possibly even false-positive findings. The images were re-evaluated for PD signal (assigning 1 point for one spot of signal, 1.5 for 2 or 3 spots, 2 for confluent small area or 3 points for confluent large area). When excluding increased thickness of knee entheses and using the re-evaluated PD scores the median MASEI was resp. 13 (IQR 10–22.5), 13.5 (IQR 9.5–18) and 3 (IQR 1.5–8) (Table 1). Conclusions US structural changes and inflammation in the entheses are common in both early and established PsA patients using the MASEI. In healthy young adults US enthesitis was only observed around the knee. MASEI ultrasound score differentiated PsA patients from healthy volunteers when dropping the knee tendon enthesis thickness and applying a refined Power Doppler score. Our findings need to be confirmed in a larger cohort of healthy controls and patients. References de Miguel E, Cobo T, Munoz-Fernandez S, Naredo E, Uson J, Acebes JC, et al. Validity of enthesis ultrasound assessment in spondyloarthropathy. Ann Rheum Dis. 2009;68(2):169–74. Disclosure of Interest None declared