A. Delle Sedie

Risk factors for osteoporosis in female patients with systemic lupus erythematosus

In the last years it has been recognized that patients with systemic lupus erythematosus (SLE) are at high risk of osteoporosis (OP) and fractures, both occurring through disease-specific (chronic arthritis, reduced physical activity, induction of cytokines promoting bone resorption, renal impairment, endocrine factors) and nondisease-specific mechanisms (sunshine avoidance with consequent vitamin D deficiency, glucocorticoids, immunosuppressants and chronic anticoagulants). Regarding anticoagulants, subcutaneous heparin is crucial against the risk of recurrent thromboembolism or pregnancy loss, specifically in patients with SLE and anti-phospholipid syndrome (APS). Thus heparin-induced OP represents one of the hazards of this treatment, first because heparin must be used long-term and secondly because pregnancy and lactation themselves may predispose to OP and fractures. Current data suggest the use of prophylaxis with calcium and vitamin D in all patients treated with heparin during pregnancy. Nevertheless glucocorticoid-induced OP (GIOP) is considered the most serious risk factor for OP and fractures in SLE patients. All guidelines recommend general measures and supplementation with calcium and vitamin D in all patients. However when considering premenopausal patients, there is no generally recommended treatment. Bisphosphonates, which are considered the first choice therapy for the prevention and treatment of GIOP, should be used ‘cautiously’ in these patients. Therefore the potential risks and lack of efficacy data on fracture risk reduction in premenopausal patients must be weighed against their proven efficacy in postmenopausal patients.

Antibodies to inner ear antigens in Meniere's disease

Menieres disease (MD) is an idiopathic inner ear disorder characterized by fluctuating hearing loss, episodic vertigo and tinnitus. Its aetiology is unknown, although there is growing evidence that autoimmunity may be involved in its development. Using the Western blot immunoassay, we examined the reactivity to bovine inner ear antigens of sera from a series of MD patients who had previously been extensively studied for the presence of antibodies to collagens and membrane proteins. Reactivity to inner ear antigens of molecular weight 44 and 53 kD was found in 11/25 (44%) and 10/25 (40%) of the patients, respectively; both antigens were absent in the sera of healthy donors. It is still unclear whether the antibodies to 44 and 53 kD proteins play a role in the pathogenesis of MD or if they instead represent the result of inflammation and tissue destruction. Even if the latter is true, they may contribute to the perpetuation of the disease or play a role as a cofactor in association with other mechanisms.

Ultrasound in the diagnosis of calcium pyrophosphate dihydrate deposition disease. A systematic literature review and a meta-analysis

OBJECTIVE Ultrasonography (US) demonstrated to be a promising tool for the diagnosis of calcium pyrophosphate dihydrate deposition disease (CPPD). The aim of this systematic literature review (SLR) was to collect the definitions for the US elementary lesions and to summarize the available data about US diagnostic accuracy in CPPD. METHODS We systematically reviewed all the studies that considered US as the index test for CPPD diagnosis without restrictions about the reference test or that provided definitions about US identification of CPPD. Sensitivity and specificity were calculated for each study and definitions were extrapolated. Subgroup analyses were planned by anatomical site included in the index text and different reference standards. RESULTS Thirty-seven studies were included in this review. All the studies were eligible for the collection of US findings and all definitions were summarized. US description of elementary lesions appeared heterogeneous among the studies. Regarding US accuracy, 13 articles entered in the meta-analysis. Considering each joint structure, the sensitivity ranged between 0.77 (0.63-0.87) and 0.34 (0.16-0.58) while the specificity varies between 1.00 (0.89-1.00) and 0.92 (0.16-1.00). Considering the reference standards used, the sensibility ranged between 0.34 (0.02-0.65) and 0.87 (0.76-0.99) while specificity ranged between 0.84 (0.52-1.00) and 1.00 (0.99-1.00). CONCLUSION US is potentially a useful tool for the diagnosis of CPPD but universally accepted definitions and further testing are necessary in order to assess the role of the technique in the diagnostic process.

Psoriasis, erythema nodosum, and nummular eczema onset in an ankylosing spondylitis patient treated with infliximab.

The tumour necrosis factor (TNF) antagonists infliximab (INF), etanercept (ETN), and adalimumab are highly effective in the treatment of rheumatoid arthritis and spondyloarthritides. Emerging data on the crucial role of TNF in psoriasis have also led to the successful use of anti-TNF inhibitors to treat psoriasis. Several skin abnormalities such as discoid lupus, erythema multiforme, lichenoid eruption, necrotizing vasculitis (1–3), and even new onset or exacerbation of psoriatic skin lesions have been reported in patients on therapy with TNF antagonists (4–10). We describe the case of a young woman (29 years old) affected by ankylosing spondylitis (AS) who developed psoriasis, erythema nodosum, and nummular eczema during treatment with INF. In 2001 the patient was referred to us with 10-month lumbar pain and limited spine motion. Her history disclosed previous acute anterior uveitis, no psoriasis or other skin disorders or symptoms of inflammatory

THU0345 Defining Elementary Ultrasound Lesions in Gout. Preliminary Results of Delphi Consensus and Web-Exercise Reliability

Objectives To produce consensus-based definitions of the US elementary lesions and to test their inter and intra-reader reliability by a web-based exercise. Methods The process included 2 steps: In the 1st first step, a written Delphi questionnaire was constructed on the basis of both data collected from the literature and the discussion results of OMERACT US members. This collated information resulted in 4 statements defining US lesions: double contour (DC), tophus, aggregate and erosion. The Delphi questionnaire was sent by email to 35 rheumatologist experts in US from 15 countries asking to rate their level of agreement or disagreement according to a 1-5 Likert scale (1=strongly disagree-5=strongly agree). The answers were summarized with mean scores. The 2nd step included the intra-reader reliability web-exercise. US images of both normal and gouty lesions, agreed upon in the Delphi process, were collected. A facilitator then constructed an electronic database of 110 images based on the 4 lesions. It was sent to the participants asking to read each image and determine the presence/absence of each score. A randomly selected group of 20 images was displayed twice to evaluate the intra-reader reliability. Results 34 participants responded to the questionnaires. A consensus was reached after the third Delphi round. The definitions approved were: “DC”: abnormal hyperechoic band over the superficial margin of the articular hyaline cartilage, independent of the angle of insonation and which may be either irregular or regular, continous or intermittent and can be distinguished from the cartilage interface sign; “tophus”: A circumscribed, inhomogeneous, hyperechoic and/or hypoechoic aggregation (which may or may not generate posterior acoustic shadow) which may be surrounded by a small anechoic rim; “aggregates”: heterogeneous hyperechoic foci that maintain their high degree of reflectivity even when the gain setting is minimized or the insonation angle is changed and which occasionally may generate posterior acoustic shadow; “erosions”: an intra- and/or extra-articular discontinuity of the bone surface (visible in 2 perpendicular planes). The cumulative agreement for the final 4 definitions was: 91% for DC, 81% for tophus, 90% for aggregates, and 87% for erosion. Twenty participants completed the web exercise. The inter-reader kappa values for DC, tophus, aggregates, erosion were 0.98, 0.71, 0.54 and 0.85 respectively whereas the intra-reader was 0.84. Conclusions This is the preliminary US consensus based definition of gout lesions and the first step to ensure a higher degree of homogeneity and comparability of results between studies and in daily practice. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.5580

The promising role of lung ultrasound in systemic sclerosis

Ultrasound (US) has an emergent and relevant role in the assessment of systemic sclerosis (SSc) even if there are many fields and applications that still have not been sufficiently explored. In this review, we will report an update of the available data regarding the use of US in lung involvement that might cause disability and mortality in SSc patients. Lung US does not employ ionizing radiation and is more rapid and less expensive than traditional high-resolution tomography (HRCT). Furthermore, recent initial studies have demonstrated that US scores correlated to HRCT and functional respiratory test results in SSc interstitial lung disease. The research agenda for the future should include a more profound investigation of its specificity (comparison with healthy subjects and other diseases) and sensitivity to change at follow-up, to adequately disseminate its use in daily practice and clinical trials.

Diffusion and applications of musculoskeletal ultrasound in Italian Rheumatology Units

The Musculoskeletal Ultrasound Study Group of the Italian Society of Rheumatology (SIR) was founded during the 68th SIR Congress, on November 2011. The request of activation of this group was based on the increasing interest and the widespread diffusion of ultrasound in the scientific rheumatology community and on the solid experience of some Italian rheumatologists in the field. The aims of the Study Group are to stimulate the applications and use of ultrasound in the clinical practice at the level of the Italian rheumatology units and, in addition, to develop research projects at a national level...

Radiologists and rheumatologists on performing and reporting shoulder ultrasound: from disagreement to consensus

Shoulder pain is a common condition in the rheumatologists practice, yet there are no guidelines on how to report shoulder ultrasound (US) examinations. The aim of this study was to compare scanning and reporting techniques performed by radiologists and rheumatologists and identify any discrepancies between the two. The participants in this study were five rheumatologists and two radiologists specialized in musculoskeletal US. The study was divided in 2 phases. In the first phase, each participant performed an US of 3 patients and reported the findings without knowing the patient diagnosis and the findings reported by the other operators. Other three investigators reported the US technique of each operator. Reports and images were subsequently compared to identify any discrepancies and reach consensus on a common approach. In the second phase, a US scan was performed on a fourth patient in a plenary session to assess feasibility and efficacy of the common approach The US scanning technique was similar for all operators. The differences in reporting emerged in the description of the rotator cuff disease. Radiologists provided a detailed description of lesions (measurements along 2 axis and scoring of lesions), whereas rheumatologists described carefully the inflammatory changes. The experts concluded that lesions should be measured along 2 axes and the grade of degeneration and the age of the lesion should be reported. Another difference emerged in the description of the irregularities of the bone surface. The experts concluded that the term erosion should be used only when an inflammatory joint disease is suspected. This study led to the clarification of some inconsistencies in US reporting, and represented an interesting collaborative experience between radiologists and rheumatologists.

FRI0260 Ultrasound study of pleural profile and chest high-resolution computed tomography (HRCT): diagnostic role in primary sjÖgren's syndrome-induced lung involvement

Background Ultrasound pleural irregularity (PI-US) is a novel promising tool for non-invasive diagnosis of interstitial lung involvement (ILD) in connective tissue diseases (CTDs). Few data are available on its diagnostic usefulness in primary Sjögrens syndrome (pSS)-induced ILD. Objectives a) To assess the accuracy of PI-US to diagnose ILD in pSS when compared to chest tomography (HRCT) (i.e gold standard imaging technique); b) to explore PI-US diagnostic value in early preclinical phases of lung involvement. Methods PI-US was performed by a single operator using a MyLab-25 (Esaote), 10 MHz, 5 cm linear probe. PI was defined as the loss of the normal hyperechoic linear pleural contour (score 0–2: normal, minimal and major changes at each intercostal space). Abnormal findings at HRCT were quantified by an expert radiologist according to a semiquantitative score (0–2: absent, moderate, severe). Semi-quantitative scores assigned by PI-US and HRCT to 6 lung fields (2 for the anterior, 2 for postero-superior and 2 for postero-inferior chest surface) were compared. Total and partial scores (for each lung fields) were evaluated. For statistical analysis chi-square, Mann-Whitney test, R-Spearman, and ROC-curve analysis were used. Results Validation study phase (PI-US vs HRCT): To validate PI-US technique, we enrolled 32 pSS patients [M/F:5/27; median age (IQR): 67 yrs (51.5–71); median disease duration (IQR): 7 (4–11) yrs; anti-Ro/SSA (+) 78.1%]. To be included patients should have performed a HRCT evaluation within 6 months. Thirteen patients (41%) presented HRCT lesions suggestive for ILD. HRCT total scores and PI-US total scores were strongly correlated (r=0.744, p=0.000). Similarly, PI-US and HRCT partial scores related to the postero-inferior fields showed a strong correlation one to each other (r=0.780, p=0.000). ROC-curve analysis identified a total PI-US score of 28.5 (Youden index) as able to predict HRCT-diagnosis of ILD with a sensitivity (SE) of 84.6% and a specificity (SP) of 89.5%. Analogously, a postero-inferior PI-US score of 12.5 demonstrated a SE of 100% and a SP of 89.5% for the ILD diagnosis. Prospective study phase exploring the usefulness of PI-US for ILD early pre-clinical diagnosis: We included 24 consecutive pSS patients without overt respiratory symptoms [M/F:1/23; median age (IQR): 55 yrs (47–67); median disease duration (IQR): 4 yrs (1–12); anti-Ro/SSA (+) 60.9%]. Out of them, at the end of the diagnostic work -up, four new cases of HRCT-proven pSS-ILD were diagnosed. Their PI-US mean total score was significantly higher than that observed in non-ILD patients (48±18 vs 16±12, p=0.001) as well as their mean postero-inferior PI-US score (19±9 vs 6±5, p=0.003). The total PI-US and postero-inferior PI-US cut-off retrieved in the first part of the study (i.e. 28.5 and 12.5) allowed us to identify those patients with an HRCT-proven pSS-ILD with a SE of 75% and 100%, a SP of 95% and 89.5%, a PPV of 75% and 57% and a NPV of of 95% and 100%, respectively. Conclusions Even if preliminary, this study demonstrated a strong correlation between PI-US and HRCT in the detection of ILD-pSS also in asymptomatic patients, opening new perspectives for the early non-invasive screening of lung involvement in pSS. Disclosure of Interest None declared

AB1022 The recall survey: the relationship between ultrasound synovitis and bone erosion in patients with rheumatoid arthritis

Background Ultrasound (US) has shown to be a sensitive imaging tool for the detection of subclinical signs of synovitis in patients (pts) with rheumatoid arthritis (RA); further studies are still required to delineate the impact of US findings in the management of RA pts in daily clinical practice. Objectives To investigate the relationship between US findings indicative of joint inflammation and US bone erosions at joint level in pts with RA. Methods In 2015 an educational event focused on the added value of US in RA pts was held in 22 rheumatology centers in Italy. In every center, the local rheumatologists provided RA pts to be examined by US. Pts signed an informed consent and a brief history of them was collected by the local rheumatologists (previous and current therapy, DAS28, HAQ score). Bilateral US examinations of wrists, metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints were performed by rheumatologists expert in US, to assess synovitis (joint effusion, synovial proliferation, and power Doppler (PD) signal), and bone erosions, using a Logiq E R7, General Electrics, with a 4.2–13 MHz linear probe. All US findings were scored using a 4 degree semiquantitative scoring system. Results In 465 RA pts, a total of 10.230 joints were scanned. Of these joints, 3.969 (39%) showed joint effusion and/or synovial proliferation and 1.784 (17%) were found positive for PD signal. The most frequently involved joints were the wrists followed by the second MCP joints and first MTP joints. In 749 joints US detected at least one bone erosion. The most frequently eroded joints were the wrists, the second and fifth MCP joints and the first and fifth MTP joints. A total of 226 RA pts showed at least one bone erosions and in 181 (80%) of these pts the eroded joints were found positive for PD signal. Conclusions A high prevalence of PD signal was found in the joints found eroded by US. This is the first study providing such an evidence using a portable US equipment. Disclosure of Interest None declared