A. Ariani

Ultrasound in the assessment of pulmonary fibrosis in connective tissue disorders: correlation with high-resolution computed tomography.

Objective. To investigate the correlation between ultrasound (US) B-lines and high-resolution computed tomography (HRCT) findings in the assessment of pulmonary fibrosis (PF) in patients with connective tissue disorders (CTD). Methods. Thirty-four patients with a diagnosis of CTD were included. Each patient underwent clinical examination, pulmonary function test (PFT), chest HRCT, and lung US by an experienced radiologist or rheumatologist. A second rheumatologist carried out US examinations to assess interobserver agreement. In each patient, US B-line lung assessment including 50 intercostal spaces (IS) was performed. For the anterior and lateral chest, the IS were the second to the fifth along the parasternal, mid-clavicular, anterior axillary, and medial axillary lines (the left fifth IS of the anterior and lateral chest was not performed because of the presence of the heart, which limits lung visualization). For the posterior chest, the IS assessed were the seventh to the eighth along the posterior-axillary and subscapular lines. The second to eighth IS were assessed in the paravertebral line. In each IS, the number of US B-lines under the transducer was recorded, summed, and graded according to the following semiquantitative scoring: grade 0 = normal (< 10 B-lines); grade 1 = mild (11 to 20 B-lines); grade 2 = moderate (21 to 50 B-lines); and grade 3 = marked (> 50 B-lines). Results. A total of 1700 IS in 34 patients were assessed. A significant linear correlation was found between the US score and the HRCT score (p < 0.001; correlation coefficient ρ = 0.875). A positive correlation was found between US B-line assessments and values of DLCO (p = 0.014). Both κ values and overall percentages of interobserver agreement showed excellent agreement. Conclusion. Our study demonstrates that US B-line assessment may be a useful and reliable additional imaging method in the evaluation of PF in patients with CTD.

Validity of a computer-assisted manual segmentation software to quantify wrist erosion volume using computed tomography scans in rheumatoid arthritis

BackgroundTo investigate the performance of conventional radiography (CR) for the detection of bone erosions of wrist in rheumatoid arthritis (RA) using multidetector computed tomography (CT) as the reference method and to evaluate the validity of a computer-assisted manual segmentation (outlining) technique to quantify erosion volume on CT scans.MethodsTwenty five RA patients and six controls underwent CT and radiographic evaluation of the dominant wrist on the same day. CT was performed by using a 64 GE light Speed VCT power. Wrists images were evaluated separately and scored for the presence of erosions according to the Outcome Measures in Rheumatology Rheumatoid Arthritis MRI Scoring System (RAMRIS) and the Sharp/van der Heijde scoring method. Measurements of bone erosion volumes were obtained using OsiriX medical imaging software. The mean value of the volumes of the CT bone erosions detected at two readings was used to calculate inter-rater agreement.ResultsThe overall sensitivity, specificity and accuracy of radiography for detecting erosions were 25.5%, 98.3% and 70.1%, respectively. Using computer-assisted manual segmentation (outlining) technique, erosion volume on CT measurements per subject was ranged from 0.001xa0cm3 to 2.01xa0cm3. Spearman’s RAMRIS score of each wrist bones in all subjects (nu2009=u200925) were correlated with the total erosion volume on CT (pu2009<u20090.0001), with the ratio between erosion volume and the corresponding bone volume on a percentage basis (pu2009<u20090.0001). The total Sharp/van der Heijde erosion score of the all wrist bones was correlate with the RAMRIS score (pu2009=u20090.008). The intraclass correlation coefficients (ICC) for manual segmentation showed high agreement (ICCu2009=u20090.901).ConclusionsConsidering CT as the reference method, CR showed very low sensitivity. A close correlation with CT erosion volumes supports the OMERACT RAMRIS erosion score as a semiquantitative measure of joint damage in RA. Although the computer-assisted manual segmentation can be beneficial for diagnostic decision in cross-sectional CT examinations of the wrist in RA, this technique will require further evaluation in terms of responsiveness.

Eight‐year retention rate of first‐line tumor necrosis factor inhibitors in spondyloarthritis: A multi‐center retrospective analysis

To evaluate the 8‐year survival of the first tumor necrosis factor inhibitor (TNFi) in patients with axial spondyloarthritis (SpA) or psoriatic arthritis (PsA), identify the predictive factors for withdrawal, and compare the discontinuation rates for infliximab, etanercept, and adalimumab.

Utility of an open-source DICOM viewer software (OsiriX) to assess pulmonary fibrosis in systemic sclerosis: preliminary results

To investigate the utility of an open-source Digital Imaging and Communication in Medicine viewer software—OsiriX—to assess pulmonary fibrosis (PF) in patients with systemic sclerosis (SSc). Chest high-resolution computed tomography (HRCT) examinations obtained from 10 patients with diagnosis of SSc were analysed by two radiologists adopting a standard semiquantitative scoring for PF. Pulmonary involvement was evaluated in three sections (superior, middle and inferior). For the assessment of the extension of PF, the adopted semiquantitative HRCT score ranged from 0 to 3 (0xa0=xa0absence of PF; 1xa0=xa01–20xa0% of lung section involvement; 2xa0=xa021–40xa0% of lung section involvement; 3xa0=xa041–100xa0% of lung section involvement). Further, a quantitative assessment (i.e. parameters of distribution of lung attenuation such as kurtosis and mean lung attenuation) of PF was independently performed on the same sections by a rheumatologist, independently and blinded to radiologists’ scoring, using OsiriX. The results obtained were compared with those of HRCT semiquantitative analysis. Intra-reader reliability of HRCT findings and feasibility of OsiriX quantitative segmentation was recorded. A significant association between the median values of kurtosis by both the quantitative OsiriX assessment and the HRCT semiquantitative analysis was found (pxa0<xa00.0001). Moreover, kurtosis correlated significantly with the mean lung attenuation (Spearman’s rhoxa0=xa00.885; pxa0=xa00.0001). An excellent intra-reader reliability of HRCT findings among both readers was obtained. A significant difference between the mean time spent on the OsiriX quantitative analysis (mean 1.85xa0±xa0SD 1.3xa0min) and the mean time spent by the radiologist for the HRCT semiquantitative assessment (mean 8.5xa0±xa0SD 4.5xa0min, pxa0<xa00.00001) was noted. The study provides the new working hypothesis that OsiriX may be a useful and feasible tool to achieve a quantitative evaluation of PF in SSc patients.

Ultrasound Learning Curve in Gout: A Disease‐Oriented Training Program

To describe the learning curve of rheumatologists with limited experience using ultrasound (US) attending an intensive disease‐oriented training program focusing on the skills required to obtain and interpret US signs of monosodium urate (MSU) crystal deposits in joint and periarticular tissues.

FRI0560 Quantitative ct indexes in the evaluation of interstitial lung disease related to rheumatoid arthritis

Background In rheumatoid arthritis (RA), interstitial lung disease (ILD) is the most common pulmonary complication and it is associated with poor prognosis. The gold standard to detect ILD is the chest Computed Tomography (CT). CT semiquantitative scoring and quantitative methods are used to estimate the extension of ILD; however the first ones are time consuming and they have a considerable inter/intra-observer variability. Quantitative scores are based on the detection of the parameters of distribution of lung attenuation (also called quantitative CT indexes – QCTi). Previously a good correlation between QCTi calculated through an open-source program (OsiriX) and semi-quantitative score performed by experienced radiologists was demonstrated in a cohort of systemic sclerosis (SSc) patients. Furthermore, the QCTi were demonstrated to be able to discriminate between SSc subjects with different mortality risk based on ILD extent (<20%u2009vs<20%) or lung functional values. Objectives Main aim is to investigate if in RA-ILD there is a correlation between QCTi and semiquantitative scores. Secondary aims are: a) to verify if there is a difference of QTCi distribution in RA-ILD patients with severe vs mild ILD extent; b) to evaluate the discriminative ability of QTCi in identifying patients with severe ILD. Methods Two experienced radiologists assessed the ILD on chest CT of 45 patients with RA according to the semiquantitative score proposed by Goh et al. ILD extent <and >20% were considered mild and severe, respectively. All CTs were blindly processed by a rheumatologist using OsiriX to obtain the QCTi (kurtosis, skewness, mean lung attenuation). The semiquantitative scores and the QCTi were correlated through the Spearman rank test. QCTi distribution and discriminative ability were, respectively, verified using Mann-Whitney test and ROC curves. Results The majority of QCTi showed a statistically significant correlation of moderate degree (0,40<r<0,59) with the semiquantitative assessment (p-value<0.01). Patients with severe and mild ILD had dissimilar QCTi values (p<0.001). Among QCTi, kurtosis (tKurt) had the best discriminative ability (AUC=0.80, 95%u2009CI 0.65 to 0.91, p<0.0001). The best tKurt cut-off value that identifies patients with severe pulmonary involvement was 3.67. Conclusions In RA-ILD, QCTi correlate with the CT semiquantitative scores. Our preliminary findings suggest that RA-ILD severity is related to QCTi. Moreover a QCTi (tKurt) has a cut-off that can discriminate patients with severe ILD. So, QCTi may become simple tools to help the rheumatologist to quickly evaluate the severity of ILD in RA patients and estimate the prognosis. Reference [1] Ariani A, Silva M, Seletti V, et al. Quantitative chest computed tomography is associated with two prediction models of mortality in interstitial lung disease related to systemic sclerosis. Rheumatology2017Jun1;56(6):922–927. Disclosure of Interest None declared

SAT0391 The 8-Year Retention Rate of The First TNF-Inhibitor in The Treatment of Spondyloarthropathies: Real-Life Data from A Multicentric Local Registries

Background Long-term data on drug survival of TNF inhibitors (TNFi) in the treatment of spondyloarthropathies are still lacking. Objectives The aim of the study is to analyze in a setting of real-life the 8-year retention rate of the first TNFi for the treatment of psoriatic arthritis (PsA) and axial spondyloarthritis (ax-SpA) and to compare the between-group discontinuation rates for each TNFi (infliximab [IFX], etanercept [ETN], and adalimumab [ADA]). Methods Data were retrospectively extracted from four local registries including all patients affected by PsA and ax-SpA treated with a biologic drug between January 2005 and May 2015. The analysis was limited to patients treated with IFX, ETN, or ADA as first-line biologic agent, with at least 1-year follow-up period. The 8-year drug survival was evaluated by Kaplan-Meier method and the risk for discontinuation among the 3 treatment groups was compared by a stratified log-rank test. Results The study population (614 patients) included 316 ax-SpA (69.9% male, mean age [±SD] 42.8 [±12.1] years, mean disease duration 7.2 [±7.9] years), treated with ADA (n=95), ETN (n=42), or IFX (n=179); and 298 PsA (51.7% male, mean age 47.8 [±12.1] years, mean disease duration 8.8 [±7.7] years), treated with ADA (n=108), ETN (n=89), or IFX (n=101). The overall median survival on treatment of the whole study population was 117.17 months (102.84 and >117.17 months for axSpA and PsA, respectively; p=NS). The overall retention rate was 66.2% (69.5% versus 62.8% in axSpA and PsA, respectively) at 5 years and 55.5% (57.2% versus 53.4% in axSpA and PsA, respectively) at 8 years. No significant differences emerged in the comparison among ADA, ETN, and IFX in both ax-SpA group (p=0.1065) and PsA group (p=0.06). IFX and ETN showed similar survival rates in PsA and axSpA (HR 1.252, 95% CI 0.600–2.608, and HR 1.224, 95% CI 0.8441–1.774, respectively), whereas ADA showed a significantly higher survival in axSpA compared to PsA (HR 1.775, 95% CI 1.045–3.013). Overall, 265 (43.1%) patients (129 [43.2%] PsA and 133 [42.1%] axSpA), stopped the first course TNFi. Inefficacy led to discontinuation in 115 (18.7%) patients (65 [21.8%] PsA and 50 [15.8%] axSpA), without significant differences between the two disease groups (p=0.1076). Adverse events led to discontinuation in 88 (14.3%) patients, (43 [14.4%] PsA and 45 [14.2%] axSpA), without significant differences between PsA and axSpA (p=0.9049). Conclusions In a real-life setting, the 8-year retention rate of the first TNFi in the treatment of spondyloarthropathies was about 50%, with no significant difference between ax-SpA and PsA. The risk of stopping IFX and ETN treatment was similar in both ax-SpA and PsA group, whereas ADA showed a higher survival in axSpA group. Disclosure of Interest None declared

SAT0504 Ultrasound Learning Curve in Gout: a Disease-Oriented Training Programme

Background Ultrasound (US) has gained considerable interest among Rheumatologists in the assessment of patients with gout due to its usefulness in both clinical practice and research activity. While a solid and still growing body of evidence supports its use in daily rheumatological practice, operator dependency and the long learning curve represent the main limitations. Objectives To describe the learning curve of Rheumatologists with limited experience in US attending an intensive disease-oriented training programme focusing on the skills required to obtain and interpret US signs of monosodium urate (MSU) crystal deposits at joint and periarticular tissues. Methods Three investigators participated in a seven-days training programme, carried out on 12 male patients with gout. The agreement between the expert and the beginners was calculated in 4 sessions on eight patients with gout The US assessment was performed at the following anatomic sites: second and third metacarpophalangeal (MCP) joints; knee, tibiotalar and first metatarsophalangeal (MTP) joints; second and third finger flexors; quadriceps and patellar posterior tibialis; peroneus longus and brevis, and Achilles tendons. The presence or absence of synovial fluid/synovial hypertrophy, double contour sign, intra- or periarticular and intratendinous tophi, bursitis, bone erosions was recorded. Results A total of 12 patients with gout (all males) were included. Eight patients were scanned directly by all of the investigators during the four sessions of the US evaluation, whereas four patients were scanned during hands-on and practical sessions by the expert sonographer. A total of 416 anatomical sites (for each patient: 10 joints, four finger flexor tendons, two quadriceps tendons, two patellar tendons, two posterior tibialis tendons, four peroneous tendons, and two Achilles tendons) were studied. Both κ values and overall agreement percentages of qualitative assessments of US gout findings showed, at the end of exercise, moderate to excellent agreement, while in the first session, poor/fair agreement was obtained (Beginner 1 (κ values at I and IV session)= synovitis 0.334–0.875 double contour sign 0.184–0.762, intra- or periarticular intratendinous tophi 0.226-709, bursitis 0.429-0.673, bone erosions 0.210-0.810. Beginner 2 (κ values at I and IV session)= synovitis 0.310-0.769 double contour sign 0.133-0.709, intra- or periarticular intratendinous tophi 0.211-0.840, bursitis 0.429-0.818, bone erosions 0.364-0.909). Beginners’ examinations at the end of the training session including sensitivity, specificity, and feasibility of the beginners were also improved. Conclusions After 1 week of the disease-oriented training programme, Rheumatologists with limited experience in US were satisfactorily able to detect and interpretthe mainUS signs indicative of MSU crystal deposits at different tissues in patients with gout. Disclosure of Interest None Declared

SAT0406 Quantification of interstitial pulmonary fibrosis in systemic sclerosis using an open-source dicom viewer software (OSIRIX)

Background Interstitial pulmonary fibrosis (IPF) is a frequent manifestation in patients with systemic sclerosis (SSc). The severity of lung involvement may vary considerably depending on the underlying disease and it can be often the cause of death of these patients (1). Currently chest high resolution computed tomography (HRCT) is considered the “gold-standard” for the diagnosis and disease activity monitoring of IPF (2). The recent availability of open sources DICOM viewer softwares such as OsiriX (3) opens up a new research area for the rheumatologist to assess the IPF. Objectives To investigate the correlation between a open source (OsiriX) software and HRCT findings in the assessment of IPF in patients with SSc. Methods Sixty two patients with diagnosis of SSc were enrolled. All patients showed an IPF at HRCT which has been interpreted by two expert radiologist. Spirometric pulmonary function tests and DLco were also performed. Both radiologist indipendently performed an analysis of the HRCT findings of all patients in order to score the IPF. Successively they reached an agreement by a discussion to obtain a consensus for a single score. Afterwards, an experienced OsiriX user rheumatologist, independently and blinded to radiologists’ scoring, quantified the overall extent of IPF in all patients using Osirix, which is a multidimensional DICOM viewer software designed to display, interpret and analyze large sets of multidimensional and multimodality images with many tools that allow the user to perform post-processing algorithms. These results were compared with those obtained by the lectures of the radiologists. Results A total of 62 SSc patients were assessed. A highly significant correlation between radiologists’ scoring and OsiriX HRCT quantitative assessment of IPF was found (p≤0.0001). In particular there was a significant correlation between quantitative evaluation and visual scoring stratified according to overall extension and fibrosis (both p≤0.0001). No correlation was found between quantitative assessment and DLco values (p=0.73). Conclusions Our results provide a new working hypothesis in favour of the utility of OsiriX in perfoming an objective IPF evaluation which could be very helpful in assessing and monitoring SSc patients. References Tyndall et al. Causes and risk factors for death in systemic sclerosis: a study from the EULAR Scleroderma Trials and Research (EUSTAR) database. Ann Rheum Dis 2010; 69 (10):1809–15. Wells. High-resolution computed tomography and scleroderma lung disease. Rheumatology (Oxford) 2008; 47 (Suppl 5):v59-61. Rosset et al. OsiriX: an open-source software for navigating in multidimensional DICOM images. J Digit Imaging 2004;17 (3): 205-16. Disclosure of Interest None Declared