POS0011 COMPARISON OF PSYCHOMETRIC PROPERTIES OF FOUR GLOBAL MEASURES OF PRESENTEEISM IN PATIENTS WITH OSTEOARTHRITIS AND INFLAMMATORY ARTHRITIS: A EULAR-PRO STUDY

Background

Work is an important outcome for people with inflammatory arthritis (IA including PsA, RA, AxSpA) and osteoarthritis (OA). It is known that people with IA and OA are at increased risk of sick leave and have to stop working early due to ill health. In addition to being at increased risk of becoming work disabled and increased absenteeism, high levels of presenteeism (i.e. reduced productivity/limited ability to work due to ill health whilst at work) have also been reported. Several instruments exist to measure presenteeism, including single-item global measures and multi-item instruments. In some studies using single-item global instruments may be more feasible. However, available global instruments differ in concept, recall period and reference. It is important to understand which of the measures have good psychometric properties before using them in clinical studies.

Objectives

To assess the psychometric properties of four global presenteeism instruments.

Methods

Patients with IA or OA were recruited via rheumatology outpatient clinics to a large international, longitudinal observational study including 8 European countries and Canada. Participants completed a survey at baseline, 1, 2, 3, 4 wks, 2 months and 3 months. The four global measures of presenteeism included: Work Productivity and Activity Impairment Questionnaire (WPAI), Work Productivity Scale–Rheumatoid Arthritis (WPS-RA), Work Ability Index (WAI) and the Quality*Quantity questionnaire (QQtotal/10) scale. To facilitate score interpretation the WAI and QQtotal were reversed. Pain was measured using an 11-point Likert scale. Spearman correlations were calculated between the presenteeism measures and the Workplace Activity Limitations Scale (WALS), a validated multi-item measure of presenteeism, and HAQ to evaluate construct validity (validity: r <0.50=low; r >0.50-<0.70=moderate; r >0.70=high). Test-retest reliability of the 4 presenteeism scales (baseline-1wk) was measured applying ICC in patients with stable disease (i.e. same pain score at baseline and 1wk) (reliability: ICC<0.40=poor; ICC 0.40-0.75=fair to good; ICC >0.75=excellent). Responsiveness during 3 months was measured comparing patients with improvement in pain score (>1 point improvement in pain score (~MCID pain)) with patients with no change or worsening in pain score. The two groups were compared applying Mann Whitney U test.

Results

This international study included 550 patients with a mean age of 47.8 (SD 9.9) yrs and 61.4% were female. Mean (SD) disease duration since diagnosis was 10.8 (10.4) yrs and 91.2% had IA. Mean (SD) presenteeism scores at baseline were: WPAI=2.9 (2.7); WPS-RA=3.4 (2.7); WAI=2.7 (2.4); and QQtotal=3.1 (3.2). The correlations between the global measures and with WALS and HAQ were moderate to good, except for QQtotal and HAQ which was low (Table 1). In patients with the same stable pain scores at baseline-1wk (n=141) ICC scores were good to excellent, respectively: WPAI (0.771), WPS-RA (0.752), WAI (0.663), and QQtotal (0.650). An improvement in pain during the 3 month study duration was observed in 145/381 (38%) of the patients. In these patients a significant reduction in mean (SD) change presenteeism was observed for all four presenteeism scales compared to those with no change or worsening of the pain score: WPAI (-1.0 (2.37) vs 0.68 (2.40), p<0.01); WPS-RA (-0.76 (2.57) vs 0.43 (2.10), p<0.001); WAI (-0.09 (2.34) vs 0.41 (2.46), p<0.001); QQtotal (-0.57 (3.16) vs 0.79 (3.1), p<0.01).

Table 1.WPAIWPS-RAWAIQQtotalWALSHAQWPAI-0.81640.59920.51840.62690.5592WPS-RA-0.58360.52170.60550.5669WAI-0.58660.52310.5168QQtotal-0.50250.4367

Conclusion

The psychometric properties of all 4 global presenteeism scales were moderate to good, with slightly better scores for both the WPS-RA and WPAI instruments both measuring the impact of OA and IA on productivity.

Disclosure of Interests

Suzanne Verstappen Consultant of: EUOSHA, Grant/research support from: AbbVie, BMS. EULAR, Annelies Boonen Speakers bureau: Abbvie / Galapagos, Consultant of: Galapagos, Sarah Wilkinson: None declared, Dorcas Beaton: None declared, Ailsa Bosworth: None declared, José Canas da Silva: None declared, Gloria Crepaldi: None declared, Sabrina Dadoun: None declared, Cathie Hofstetter: None declared, Carina Mihai Speakers bureau: Boehringer-Ingelheim, Mepha, MED Talks Switzerland, Consultant of: Boehringer-Ingelheim, Janssen, Grant/research support from: Roche, Boehringer-Ingelheim, Sofia Ramiro Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB, Sanofi, Grant/research support from: Grant: AbbVie, Galapagos, Novartis, Pfizer, UCB, Garifallia Sakellariou Consultant of: Abbvie, BMS and Galapagos., Grant/research support from: Abbvie, BMS and Galapagos., Sandra Meisalu: None declared, Johan K Wallman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Novartis, Grant/research support from: AbbVie, Amgen, Eli Lilly, Novartis, Pfizer., Diane Lacaille: None declared

Portuguese recommendations for the prevention, diagnosis and management of primary osteoporosis - 2018 update

BACKGROUND

Advances in osteoporosis (OP)case definition, treatment options, optimal therapy duration and pharmacoeconomic evidence in the national context motivated the Portuguese Society of Rheumatology (SPR) to update the Portuguese recommendations for the diagnosis and management of osteoporosis published in 2007.

METHODS

SPR bone diseases' working group organized meetings involving 55 participants (rheumatologists, rheumatology fellows and one OP specialist nurse) to debate and develop the document. First, the working group selected 11 pertinent clinical questions for the diagnosis and management of osteoporosis in standard clinical practice. Then, each question was investigated through literature review and draft recommendations were built through consensus. When insufficient evidence was available, recommendations were based on experts' opinion and on good clinical practice. At two national meetings, the recommendations were discussed and updated. A draft of the recommendations full text was submitted to critical review among the working group and suggestions were incorporated. A final version was circulated among all Portuguese rheumatologists before publication and the level of agreement was anonymously assessed using an online survey.

RESULTS

The 2018 SPR recommendations provide comprehensive guidance on osteoporosis prevention, diagnosis, fracture risk assessment, pharmacological treatment initiation, therapy options and duration of treatment, based on the best available evidence. They attained desirable agreement among Portuguese rheumatologists. As more evidence becomes available, periodic revisions will be performed. Target audience and patient population: The target audience for these guidelines includes all clinicians. The target patient population includes adult Portuguese people. Intended use: These recommendations provide general guidance for typical cases. They may not be appropriate in all situations - clinicians are encouraged to consider this information together with updated evidence and their best clinical judgment in individual cases.

Effect of Comedication With Conventional Synthetic Disease-Modifying Antirheumatic Drugs on Retention of Tumor Necrosis Factor Inhibitors in Patients With Spondyloarthritis: A Prospective Cohort Study

OBJECTIVE

To evaluate whether use of comedication with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) influences the retention of tumor necrosis factor inhibitors (TNFi) in patients with spondyloarthritis (SpA).

METHODS

Patients with SpA from the Rheumatic Diseases Portuguese Register who started treatment with their first TNFi between 2001 and 2014 were included in this study. Cox regression analysis was used to estimate the effect of comedication with csDMARDs on TNFi retention in 2 types of models: a model in which baseline (time-fixed) variables were included, and a second model incorporating time-varying variables, including sociodemographic features, measures of disease activity, measures of physical function, and cotreatment with other drugs (nonsteroidal antiinflammatory drugs and oral steroids). To control for possible confounding by indication, the effect of csDMARD comedication on TNFi retention was also tested after adjustment for the treatment propensity score.

RESULTS

In total, 954 patients were included in the study, of whom 289 (30.3%) discontinued treatment with their first TNFi after a median follow-up time of 2.5 years (range 0.08-13 years). Inefficacy was the most common reason for TNFi discontinuation (55.7% of patients). In the multivariable analyses, comedication with csDMARDs had no measurable effect on TNFi retention, neither in the baseline model (hazard ratio [HR] 0.83, 95% confidence interval [95% CI] 0.59-1.16) nor during follow-up in the model adjusted for time-varying covariates (HR 1.07, 95% CI 0.68-1.68). The effect of csDMARD comedication remained nonsignificant after propensity score adjustment.

CONCLUSION

Comedication with csDMARDs does not prolong TNFi retention in patients with SpA in clinical practice, suggesting that there is no benefit conferred by the concomitant use of these drugs.

Economic considerations and patients' preferences affect treatment selection for patients with rheumatoid arthritis: a discrete choice experiment among European rheumatologists

OBJECTIVE

To compare the value that rheumatologists across Europe attach to patients' preferences and economic aspects when choosing treatments for patients with rheumatoid arthritis.

METHODS

In a discrete choice experiment, European rheumatologists chose between two hypothetical drug treatments for a patient with moderate disease activity. Treatments differed in five attributes: efficacy (improvement and achieved state on disease activity), safety (probability of serious adverse events), patient's preference (level of agreement), medication costs and cost-effectiveness (incremental cost-effectiveness ratio (ICER)). A Bayesian efficient design defined 14 choice sets, and a random parameter logit model was used to estimate relative preferences for rheumatologists across countries. Cluster analyses and latent class models were applied to understand preference patterns across countries and among individual rheumatologists.

RESULTS

Responses of 559 rheumatologists from 12 European countries were included in the analysis (49% females, mean age 48 years). In all countries, efficacy dominated treatment decisions followed by economic considerations and patients' preferences. Across countries, rheumatologists avoided selecting a treatment that patients disliked. Latent class models revealed four respondent profiles: one traded off all attributes except safety, and the remaining three classes disregarded ICER. Among individual rheumatologists, 57% disregarded ICER and these were more likely from Italy, Romania, Portugal or France, whereas 43% disregarded uncommon/rare side effects and were more likely from Belgium, Germany, Hungary, the Netherlands, Norway, Spain, Sweden or UK.

CONCLUSIONS

Overall, European rheumatologists are willing to trade between treatment efficacy, patients' treatment preferences and economic considerations. However, the degree of trade-off differs between countries and among individuals.

Clinical features and long-term outcomes of systemic lupus erythematosus: comparative data of childhood, adult and late-onset disease in a national register

Systemic lupus erythematosus (SLE) affects predominantly women at reproductive age but may present at any age. Age at disease onset has a modulating effect on presentation and course of disease, but controversies persist regarding its impact on long-term outcome. Our aims were to characterize clinical features, co-morbidities and cumulative damage in childhood-onset, adult-onset and late-onset SLE. Patients with childhood-onset SLE fulfilling ACR 1997 criteria were identified in a nationwide register-Reuma.pt/SLE (N = 89) and compared with adult-onset and late-onset counterparts matched 1:1:1 for disease duration. 267 SLE patients with mean disease duration of 11.9 ± 9.3 years were analyzed. Skin (62 %), kidney (58 %), neurological (11 %) and hematologic involvement (76 %) were significantly more common in childhood-onset SLE and disease activity was higher in this subset than in adult- and late-onset disease (SLEDAI-2K 3.4 ± 3.8 vs. 2.2 ± 2.7 vs. 1.6 ± 2.8, respectively; p = 0.004). Also, more childhood-onset patients received cyclophosphamide (10 %) and mycophenolate mofetil (34 %). A greater proportion of women (96 %), prevalence of arthritis (89 %) and anti-SSA antibodies (34 %) were noted in the adult-onset group. There was a significant delay in the diagnosis of SLE in older ages. Co-morbidities such as hypertension, diabetes and thyroid disease were significantly more frequent in late-onset SLE, as well as the presence of irreversible damage evaluated by the SLICC/ACR damage index (20 vs. 26 vs. 40 %; p < 0.001). Greater organ involvement as well as the frequent need for immunosuppressants supports the concept of childhood-onset being a more severe disease. In contrast, disease onset is more indolent but co-morbidity burden and irreversible damage are greater in late-onset SLE, which may have implications for patients' management.

Characterization of damage in Portuguese lupus patients: analysis of a national lupus registry

Background: Although the survival rate has considerably improved, many patients with systemic lupus erythematosus (SLE) develop irreversible organ damage. Objectives: The objectives of this paper are to characterize cumulative damage in SLE patients and identify variables associated with its presence and severity. Methods: A cross-sectional analysis of SLE patients from the Portuguese Lupus register Reuma.pt/SLE in whom damage assessment using the SLICC/ACR-Disability Index (SDI) was available was performed. Predictor factors for damage, defined as SDI ≥ 1, were determined by logistic regression analyses. A sub-analysis of patients with severe damage (SDI ≥ 3) was also performed. Results: In total, 976 patients were included. SDI was ≥1 in 365 patients, of whom 89 had severe damage. Musculoskeletal (24.4%), neuropsychiatric (24.1%) and ocular (17.2%) domains were the most commonly affected. Older age, longer disease duration, renal involvement, presence of antiphospholipid antibodies and current therapy with steroids were independently associated with SDI ≥ 1. The subpopulation with severe damage had, in addition, a greater interval between the first manifestation attributable to SLE and the clinical diagnosis as well as and more frequently early retirement due to SLE. Conclusions: This large lupus cohort confirmed that demographic and clinical characteristics as well as medication are independently associated with damage. Additionally, premature retirement occurs more often in patients with SDI ≥ 3. Diagnosis delay might contribute to damage accrual.

[Rheumatic expression of secondary syphilis]

Syphilis is a disease caused by Treponema pallidum infection with protean clinical manifestations. Musculoskeletal complaints are however uncommon and most of the time mild. Occasionally they can dominate the clinical picture and simulate a variety of rheumatic diseases. The authors present the clinical case of a 33-year-old woman who developed a lupus-like syndrome in the postpartum, characterized by polyarthritis, elevated acute phase reactants and positive antinuclear antibodies (ANA). Physical examination revealed a macular non-pruriginous skin rash involving the trunk, upper limbs and palms. The Rapid Plasma Reagin (RPR) and Treponema Pallidum Hemaglutination (TPHA) tests gave a positive result and the patient was diagnosed as secondary syphilis and medicated with 2.4 MU of benzathine penicillin intramuscular weekly for 3 weeks, with complete resolution of clinical signs and ANA negativation. The association of rash and arthritis may occur in several rheumatic diseases but in the presence of palmoplantar involvement, the possibility of syphilis infection should not be overlooked.

Biologicals and switch in rheumatoid arthritis throughout time - are we being more aggressive?

OBJECTIVES

To investigate the switches performed in patients with rheumatoid arthritis under biological therapy and specifically comparing the switches from earlier days with more recent switches.

PATIENTS AND METHODS

Patients with rheumatoid arthritis under biological therapy followed at Hospital Garcia de Orta, Almada, and included in the Rheumatic Diseases Portuguese Register (Reuma.Pt) were included in this study. Switches occurring before and after January 2007 were compared with respect to patients' demographic and clinical characteristics, such as disease activity and duration of biological therapy. The survival of the first biological agent was compared between patients starting biological therapy before and after 2007. EULAR response and remission rate at the last evaluation were calculated. Comparisons between groups were established using a t-test or chi--square, as appropriate. Survival curves of the first biological were compared through the logrank test.

RESULTS

In total, 123 patients were included in the analysis (mean age 57.0 ± 13.1 years and mean disease duration 11.7 ± 8.0 years). A total of 85 switches were documented, 20% of which took place before 2007. Comparing the switches before and after 2007, the latter were registered among older patients (recent switches 56.2 ± 12.9 years vs older switches 48.9 ± 11.0 years, p=0.04) and with a shorter duration of the first biological agent (recent switches 461.9 ± 293.2 days vs older switches 773.7 ± 475.8 days, p=0.03). No further significant differences were found, including the disease activity. The survival of the first biological was shorter in patients starting biological therapy after 2007 (2949 days for biological onset before 2007 and 818 days for onset after 2007, p <0.001). A good EULAR response was achieved by 19% and 30% of the patients, before and after 2007, respectively (p = 0.23). Remission was achieved by 14% and 22% of the patients, before and after 2007, respectively (p = 0.30).

CONCLUSIONS

Switches were more frequently performed in more recent years, in older patients and with a shorter duration of biological therapy. A trend towards a better and more targeted control of the disease could be discussed in light of our results. Although switches were more frequently performed in more recent years, in older patients and with a shorter duration of biological therapy, there is still room for improvement when aiming at remission, for example by applying a tighter therapy strategy like the "treat to target model".

[Mixed cryoglobulinemia]

The authors describe two clinical cases of cryoglobulinemia. A 70 years old woman, having skin ulcers on lower limbs, arthralgias, paresthesias and constitutional symptoms, for about 10 months. Exams revealed mild anemia, elevation of the biological parameters of inflammation and aminotransferases, positive cryoglobulin and rheumatoid factor in serum, and a severe reduction in C4 complement fraction. Hepatitis C virus (HCV) serology was negative. Idiopathic mixed cryoglobulinemia was diagnosed and corticosteroid therapy started. Given the lack of response, cyclophosphamide and plasmapheresis were added. Two weeks later the patient died in septic shock. The second case refers to a 41 years old female, with untreated hepatitis C who developed over a 6 month period petechiae and livedoid lesions on the lower limbs, peripheral neuropathy, and constitutional symptoms and was admitted with intestinal necrosis. Exams were consistent with the diagnosis of mixed cryoglobulinemia associated, with HCV. She started therapy with ribavirin and pegylated interferon-alpha, with improvement.

Body composition phenotypes in systemic lupus erythematosus and rheumatoid arthritis: a comparative study of Caucasian female patients

OBJECTIVES

The amount and distribution of fat and lean mass have important implications for health and systemic inflammation may represent a risk for altered body composition. The aim of this study was to analyse whether changes in body composition are similarly associated with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), two inflammatory conditions of different pathogenesis.

METHODS

Body mass index (BMI), waist circumference, fat mass (FM) and fat-free mass (FFM) were measured in 92 women with SLE, 89 with RA and 107 controls. Results were compared among the 3 groups and correlations of FM percentage were explored within SLE and RA.

RESULTS

Abnormal body composition was more frequent in women with SLE and RA than in non-inflammatory controls, despite having a similar BMI. RA diagnosis was significantly associated with overfat (OR=2.782, 95%CI 1.470-5.264; p=0.002) and central obesity (OR=2.998, 95%CI 1.016-8.841; p=0.04), while sarcopenia was more common among SLE (OR=3.003; 95%CI 1.178-7.676; p=0.01). Sarcopenic obesity, i.e. the coexistence of overfat with sarcopenia, was present in 6.5% of SLE and 5.6% of RA women, but no controls. Independent correlations of FM percentage in women with SLE included smoking, disease activity and CRP. In RA, education, disease activity and cumulative corticosteroid dose were identified as independent predictors of FM percentage.

CONCLUSIONS

Women with SLE or RA diagnosis are more likely to have abnormal body composition phenotype, with some differences existing between these two conditions. Changes in body composition are partly explained by the inflammatory burden of disease and its treatment.

[Myalgia of the girdle in the elderly: an uncommon etiology]

We describe the clinical case of 80 years, caucasian woman, with personal history of osteoporosis and chronic normochromic normocytic anemia (NN). She had a three month history of myalgias of the girdle, stiffness in the morning, exceeding 1 hour, associated with inflammatory arthralgia of the small joints of hands and feet. Complementary exams showed normocytic normochromic anemia with Hg 9.8 g/dL; ESR 44 mm/h; CRP 7 mg/dL. Given the profile suggestive of Polymyalgia Rheumatica started prednisolone 10 mg/day with favorable clinical response. Four months after treatment she started paresthesias of right hand and foot, polaquiuria, petequial lesions in lower limbs and inability to walk; there was worsening of anemia and elevation of the biological parameters of inflammation, beginning of renal insufficiency with creatinine clearance 22 ml/min, proteinuria and eritrocituria. Renal biopsy was compatible with Wegener's granulomatosis/microscopic poliangeite. Vasculitis is a rare disease of the elderly and its clinical presentation is varied. The arteritis of giant cells and Polymyalgia Rheumatica are more common in the elderly. It is not often Polymyalgia-like presentation in cases of Wegener's granulomatosis/microscopic polyangitis.

Assessment of salivary gland function in Sjögren's syndrome: the role of salivary gland scintigraphy

Salivary gland scintigraphy (SGS) is a non invasive method of salivary gland function assessment. This technique is easy to perform, reproducible and well tolerated by patients. Additionally, an abnormal salivary gland scintigraphy result is accepted by the American-European consensus group as a criterion for the diagnosis of Sjögren's syndrome. Scintigraphic evaluation of salivary gland function also plays an important role in therapeutic decision and patient follow-up. Schall's categorical classification is usually considered the standard method for salivary scintigraphy interpretation, though subjective and with limited capacity to discriminate borderline results. In order to improve the diagnostic accuracy of SGS, there has been an increasing interest in the quantification of glandular function. However, the debate on the most reliable and suitable parameters for the diagnosis of SS persists.

[Flexibilization of infliximab dose interval in the treatment of ankylosing spondylitis]

OBJECTIVE

The aim of this study was to access the maintenance of therapeutic response in patients with ankylosing spondylitis (AS) receiving infliximab, after prolongation of the interval between infusions.

MATERIAL AND METHODS

In AS patients with sustained therapeutic response to infliximab administered every six weeks, a prolongation of the interval between infusions was proposed. The therapeutic response was evaluated using Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), pain, stiffness, patient's global evaluation and acute phase reactants (ESR and CPR).

RESULTS

Twenty patients participated in the study. Sixteen were male, with a mean age of 40.3 +- 10.9 years and mean disease duration of 12 +- 9.4 years. The initial BASDAI was 59.5 +- 22.8 and initial BASFI 50.7 +- 27. The interval between infusions was lengthened to 8 +- 1 weeks (minimum 7; maximum 10) and this change occurred between 12 and 142 weeks (median 21) of treatment. The mean followup after changing the therapeutic regimen was 86 +- 45 weeks. Sixty-five percent (13/20) of the patients maintained an adequate response.

CONCLUSIONS

Two thirds of AS patients with sustained therapeutic response to infliximab administrated every six weeks maintained an adequate response with prolongation of interval between infusions. Therefore the increase of the interval between infusions seems to be an adequate option in selected patients.

[Characterization of a Portuguese population with systemic lupus erytematosus]

To characterize systemic lupus erythematosus (SLE) in Portuguese patients and to identify differences in diseases expression related to sex and ethnicity.

PATIENTS AND METHODS

Retrospective cohort analysis of patients with SLE followed at five Rheumatology Departments between 1976 and 2006. Demographic data, diseases manifestations, medications used, co morbidity and damage scores were recorded.

RESULTS

Five hundred forty four patients were studied, 93% female, 89% Caucasians, with an average age at disease diagnosis of 35 years. The most frequent clinical features were musculoskeletal (91%), cutaneous and mucous membrane (90%) and the hematological involvement (58%). Renal diseases and serositis occurred more often in males while myositis was more common in black patients. Immunological features included the presence of anti-nuclear antibodies in 99% of the patients, anti-DNA (76%) anti-SSA (33%), anti-SSB (20%), anti-RNP (26%), anti-Sm (22%), anticardiolipine (31%) and lupus anticoagulant (21%). Anti-SSA, anti-RNP, and anti-Sm antibodies were significantly more prevalent among black patients. The presence and severity of damage measured by SLICC/ACR was similar between sexes and ethnicities. In multivariate analyses diseases duration and the presence of hypertension showed a positive association, while educational and antimalarials were negatively associated with the presence of damage.

CONCLUSION

In this cohort of Portuguese patients SLE present clinical features similar to those observed in other predominantly Caucasian populations, albeit a higher prevalence of anti-RNP and anti-Sm antibodies was observed. Some particular features were associated with male sex and African ethnicity. Some socio-demographic and clinical variables were associated with damage accrual.

[Osteopoikilosis: 2 clinical cases]

Osteopoikilosis is a rare, benign and autosomal dominant bone disease. It is usually asymptomatic and diagnosed as a radiological finding. Plain X- Ray films show multiple sclerotic lesions on periarticular areas, epiphyses and metaphyses of long tubular bones. The authors describe two cases of osteopoikilosis in subjects belonging to the same family (brothers).

Exercise stress echocardiography for detection of pulmonary arterial hypertension in a patient with systemic sclerosis

The authors report the case of a 57-year-old patient, diagnosed with systemic sclerosis 16 years ago. She had been followed in the rheumatology outpatient clinic since 2003 and complained of marked fatigue and dyspnea on exertion. In addition to full medical evaluation, she also underwent standard Doppler echocardiography at rest, which was unremarkable, and exercise stress echocardiography. In the latter examination, she was diagnosed with pulmonary arterial hypertension, later confirmed during right heart catheterization. The authors discuss the potential value of this methodology for the study of patients with systemic sclerosis.

[Back pain and dorsal kyphosis in childhood]

Juvenile idiopathic osteoporosis (JIO) is a rare condition of unknown aetiology, with pre-pubertal onset and frequently spontaneous remission after puberty. We report a case of a 14 years old boy, which two years before began dorso-lumbar pain with dorsal kyphosis. At the age of 12, he was on percentil 25 for height and had no other symptoms or alterations on physical exam. He had multiple vertebral fractures, a low serum vitamin D, and a Z-score in lumbar spine of -5,3. Diagnosis of JIO was made after excluding other causes of juvenile osteoporosis. He was submitted to pamidronate therapy and after six months showed clinical and bone mineral density improvement. At the age of 14 he is asymptomatic. The authors present this clinical case because of is rarity and to point out that although many cases have spontaneous remission, without any therapy, some may persist and become more serious, with pain and multiple fractures, justifying therapeutic intervention.