A. Nasr

Ultrasound assessment of the median nerve: a biomarker that can help in setting a treat to target approach tailored for carpal tunnel syndrome patients

Ultrasonography (US) is a valuable tool for confirming the diagnosis of carpal tunnel syndrome (CTS) as it enables the detection of changes in the median nerve shape and rule out anatomic variants as well as space-occupying lesions such as ganglion cysts or tenosynovitis. This work was carried out aiming at: 1. Ultrasonography assessment of the median nerve and its neurovascular blood-flow in CTS patients before and after management. 2. Verify the possibility of using baseline US parameters as a biomarker to predict likely outcomes and frame a treatment plan for CTS patients.233 CTS subjects diagnosed based on clinical and electrophysiological (NCS) testing were included in this work. US measures at the tunnel inlet included: cross sectional area, flattening ratio and neural Power Doppler (PD) signals. Patients who had severe NCS outcomes or neurological deficit were referred for open surgical decompression; the remaining patients were given the choice of either conservative or surgical management. The main outcome variable was improvement >70% in CTS symptoms. Assessments were carried out at baseline, 1-week, 1-month and 6-months post treatment. Results revealed an inverse relation between the neural vasculature and CTS severity defined by NCS (r = − 0.648). In CTS cases treated conservatively, the US measures started to improve within 1-week, whereas in the surgically treated cohort there was an initial phase of post-operative nerve measures increase, before settling at 1-month time of follow-up. The risk of poor outcomes was significantly higher (RR 3.3) in patients with high median nerve flattening ratio. This risk was most marked in the cohort with nerve flattening associated with longer duration of illness (RR 4.3) and low PD signal (RR 4.1). The results revealed that in addition to the diagnostic value of US in CTS, the detection of increased median nerve neuro-vasculature has a good prognostic value as an indicator of early median nerve affection.

THU0358 Gray Scale and Power Doppler Ultrasound Assessment of the Median Nerve: A Biomarker That Can Help in Setting A Treat to Target Approach Tailored for Carpal Tunnel Syndrome Patients

Background Though there are various carpal tunnel syndrome (CTS) treatment options, their outcomes and long-term effects are still debatable. An accurate understanding of the predictive factors of CTS management outcomes would enable physicians and patients to make more informed decisions about an approach tailored to the patients condition and develop more accurate expectations of outcomes. Objectives 1. To assess the median nerve both by Gray-scale US and intra-neural vascular flow (using Power Doppler (PD) before and after management in subjects with CTS, and 2. to verify the feasibility of initial US parameters for prediction of management outcome. Methods 233 subjects, mean age 55.6 years, diagnosed with CTS established by clinical and electrophysiological (NCS) findings. Baseline clinical, electrophysiological severity (grade 1-6 score) and self-assessment scoring of symptoms (using the modified Boston questionnaire were recorded. US measures included: the median nerve area at tunnel inlet, the flexor retinaculum, and the flattening ratio as well as Intra-neural PD signals (grades 0-3). Surgical decompression was offered to the patients who had neurological deficit or severe NCS outcome (grade 5/6) whereas the rest were given the choice of being treated either conservatively (including local steroid injection) or surgically. The main outcome variable was improvement >25% in CTS symptoms questionnaire score and >50% of the patients overall satisfaction score. US assessments were performed at baseline, 1-week, 1-months and 6-months post treatment (whether conservative or surgically). Logistic regression analyses was used to assess the best predictive combination of preoperative findings. Results There was an inverse relation between intra-neural vasculature in the median nerve (PD score) and increasing CTS severity based on nerve conduction results (r= - 0.648). In the patients cohort treated conservatively, US measures of the median nerve started to improve within a week of local injection, whereas in those treated surgically there was an initial phase of post-operative increase of the median nerve measures, before settling at 1-month time of follow up. The risk of a poor outcome was significantly higher in the patients with high median nerve flattening ratio at the CT inlet (relative risk 3.3, 95% CI 1.73-6.43, P=0.0004). This risk was most marked in the cohort with nerve flattening associated with longer duration of illness (relative risk 4.3, 95% CI 1.82-10.29, P=0.006) and low PD signal (relative risk 4.1, 95% CI 1.71-9.47, P=0.005). Clinical predictors of poor outcome included: neurological deficit and predisposing medical conditions. Nerve conduction testing did not show significant response to management. Conclusions In addition to the diagnostic value of US in CTS, the detection of increased intra-neural vasculature of the median nerve is an indicator of early median nerve affection and has a good prognostic value. Increased flattening of the median nerve with low vascularity assessed by PD has a poor prognostic impact. Nerve conduction studies are not a good tool to monitor response to therapy, whereas US can be used to monitor median nerve changes as early as 1 week of management. Acknowledgements To Omar El Miedany for Data Recording and admin support Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.1410

SAT0072 Functional Disability: A Parameter Fit to BE A Biomarker for Inflammatory Arthritis

Background The search for markers identifying key targets for the assessment of major outcomes in Rheumatoid Arthritis (RA) has become one of the hot issues in rheumatology. Possible markers should help to identify (in early RA) the patients who are going to respond quickly to therapy with the opportunity to tailor management to the patient status. So far this target has not been achieved. Objectives To assess whether Functional Disability can be used as a valid biomarker enabling the physicians to optimally match patient with disease progression and response to treatment. Methods Retrospective study which included 481 subjects suffering from early inflammatory arthritis (Disease duration <6-months) diagnosed according to the ACR/EULAR criteria 2010. Changes from baseline to week 76 in clinical variables, patient reported outcome measures [1], including functional disability, and measures of radiographic progression were assessed in early RA patients diagnosed according to the 2010 EULAR/ACR criteria for RA and treated to Target. Radiographic progression was scored at baseline and at 76-weeks using modified Sharp score as well as US scores for number of erosions, synovial hypertrophy and vascularity (using Power Doppler). Biochemical laboratory measures included ESR, CRP and rheumatoid factor. Correlation of functional disability score to response to therapy at 3, 6 and 12 months of management as well as to work ability, development of erosions and joint affection were studied. The sensitivity and specificity of Functional disability as an indicator of prognosis was also assessed using ROC curve analysis. Results The crude functional disability score as well as the percentage changes at 3 and 6 months showed a statistically significant increase in the group with persistent inflammatory synovitis compared to the self-limiting arthritis group. Using binary logistic regression analyses to assess the association between functional disability and disease activity flare up revealed that a flare was associated with poor baseline function and quality of life measures: Functional disability [OR per 0.1 unit=1.8 (1.06–1.54), p=0.004] and Quality of Life [OR=1.12 (1.01–1.23), p=0.024]. Changes in functional disability scores were not significantly correlated to changes in inflammatory biochemical markers (ESR and CRP) levels. However, changes in the functional disability scores correlated significantly to changes in PD scores (p<0.01). In multiple conditional logistic regression analysis, factors associated with the development of joint space narrowing were worsening of functional disability score by >0.5/3, synovial thickening and synovial PD score ≥2 at both baseline and 6-months of treatment. The discriminative power had an AUC of 0.864 (95% CI 0.765 - 0.937), with Sensitivity 84%, Specificity 92% and LR + 5.6. Conclusions Functional disability met the criteria of a valid marker for rheumatoid arthritis, being objectively measured, indicator of normal and pathologic joint affection, as well as a sensitive and specific marker for response to therapy and poor prognosis. References Incorporating patient reported outcome measures in clinical practice: development and validation of a questionnaire for inflammatory arthritis. Clin Exp Rheumatol. 2010; 28(5):734. Acknowledgements To Omar El Miedany for help in data recording and admin support. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1470

AB0287 Mutual assent towards comprehensive disease control: the relationship between us measures and patient reported outcomes in early rheumatoid arthritis

Objectives Assessment of the relationship between US measures of joint inflammation/damage and patient reported outcomes (PROs): HAQ, pain and patient global assessment in early rheumatoid arthritis (early RA) patients over 5-years follow up period. Methods This longitudinal cohort of 261 patients with early RA was derived from the US monitoring study [1]. Adopting OMERACT definitions; correlations between total US scores (synovial hypertrophy, synovial fluid, Power Doppler, bone erosion and tenosynovitis) and PROs [2] namely functional disability (HAQ), pain and patient global scores were determined at 0, 1, and 5years. Radiological damage was assessed using modified Total Sharp score (mTSS). Univariate correlations as well as correlations between interval changes were assessed. Multivariable regression models were used to evaluate the associations over all time-points and their relationship to clinical disease activity measures. Results There were significant correlations (p<0.01) between total US score and HAQ (r=0.71), pain (r=0.69) and patient global scores (r=0.66) at all timepoints. The association tends to be stronger with increase disease duration (Spearman correlation 0.12 at baseline, 0.22 at 1-year and 0.41 at 5-years). Change in mTSS score at 5-years was not associated with changes in PROs. Improvements in US scores were also associated with improvements in PROs. Multivariate models revealed that synovial hypertrophy and Power Doppler scores were associated (p<0.01) with functional disability, pain and patient global assessment, controlling for clinical disease activity measures. Studying the pattern of joint involvement, it was associated significantly (p<0.01) with the US score of the affected joints. US total score at 1-year predicted subsequent 5-year HAQ score (R2=0.17). At 0, 1- and 5-years, total US scores were higher in patients whose HAQ score was >1 (9.26) compared to those below 1 (4.16, p<0.01). Conclusions the link between joint inflammation/structural damage and PROs is of critical importance to the care of patients with inflammatory arthritis. US measures of inflammation and structural damage correlated independently with physical function, pain and patient global assessments. A clear relationship between radiographic structure damage and the patients perceived remission/flare provide the basis for comprehensive disease assessment and management. References El Miedany et al. Current Rheumatology Reviews 2015; 11, 18–27. El Miedany et al. Clin Exp Rheumatol 2010; 28(5):734–44. Disclosure of Interest None declared

SAT0339 Patterns of us changes in degenerative arthritis: Early vs late osteoarthritis of the knee joint

Objectives Objective: 1. To assess the patterns of US evaluation of Knee joint osteoarthritis. 2. To evaluate the use of US as a tool for quantitative assessment of knee trochlear cartilage thickness 3. To assess whether US changes vary and can be used to stratify early versus advanced osteoarthritis of the knee joint. Methods 82 patients with OA of the knee (69% female; mean age 66.4 years) and 44 healthy (70% female; mean age 64.5 years) were recruited. The OA stage was determined according to the Kellgren/Lawrence (K/L) radiographic grading system. Knee joint US was carried out to assess for: 1. the cartilage clarity as well as the sharpness of the cartilage-synovial interface. 2. Cartilage thickness measures: the distance between the trochlear notch and the convexity of the medial trochlea was divided into 3 equal divisions and articular cartilage thickness was measured. 3. The presence of osteophytes. 4. synovitis and effusion. 5. medial and lateral meniscus displacement performed with subjects in the supine and standing positions. To assess for the reliability of US measures, the thickness at the medial and lateral condyles was measured and ICCs were calculated. To assess for the validity: κ was calculated for the agreement between US and radiographs on osteophytes. Results Five main changes in knee joint OA were identified: reduced sharpness of the anterior cartilage margins, loss of cartilage transparency, medial compartment cartilage thinning, displacement of the medical meniscus and abnormalities of the subchondral bone. Radiographic abnormalities defined by K-L criteria were: K-L1 =15%, K-L2 =27%, K-L3 =41%, K-L4 =17%. Radiographic osteophytes were present in 44% of subjects. US showed osteophytes that were not seen in X-rays of 29%. whereas joint space narrowing was seen in 27% of the patients (p<0.02). Meniscal displacement and synovitis were significantly associated with higher pain scores (p<0.01). There was a significant difference (p<0.01) between cartilage thickness at the last third of the medial mensicus in the patients versus controls (p<0.01). There was also significant difference (p<0.01) for both decreased cartilage clarity and sharpness of the cartilage-synovial interface in the patients versus control groups. Reliability: high kappa values for osteophytes (0.96), cartilage thickness (0.88) and Medial Meniscus Displacement measures (0.83). Validity: when comparing radiograph results with those of the US, the corresponding kappa values were 0.45 on the right and 0.57 on the left; demonstrating moderate agreement. Patients with early OA had: Indistinctness of the cartilage – synovial interface and loss of the clarity of the cartilage. Moderate OA patients had: moderate cartilage thinning, moderate Medial Meniscus displacement with/without osteophytes up to 2mm in length Advanced OA patients had: 1 and 2 plus severe Cartilage thinning or Medial Meniscus Displacement, osteophyte formation (>2mm in length) and irregularity of the subchondral bone. Conclusions US scanning can replace plain radiographs in the evaluation of OA of the knee joint in the clinical practice of rheumatology. US not only shows the cartilage changes reliably enough, but also the existence of osteophytes and signs of inflammation e.g. effusion and synovial hyperplasia. Disclosure of Interest None Declared

SAT0307 Treat to Target of Psoriatic Arthritis: Core Set Criteria of Minimal Disease Activity

Background Recently, the concept of “treat-to-target” has emerged as a topic of great interest in rheumatology, particularly as regards the therapeutic approach to RA patients. PsA is a multifaceted disease that may involve arthritis, skin and nail disease, enthesitis, dactylitis and axial disease. There are no agreed composite outcome measures for PsA that assess all of these differing disease manifestations. Objectives To identify a validated core set of definitions that are able to recognise patients who achieved optimal therapeutic outcomes and reached minimal disease activity (MDA) levels. Methods The conceptual definition of MDA approved at the OMERACT- 6 conference was agreed as a core set of domains for PsA. This includes: Peripheral joint activity measured using the 68 tender/66 swollen joint count, Skin activity assessed using both PASI score and Body surface area (BSA), back pain, joint pain, duration of morning stiffness and patient’s global assessment of disease activity measured using 100 mm VAS scales. The modified HAQ was used as a measure of physical function and enthesitis count was included with a maximum value of 13. In addition, ESR and CRP were assessed. Dactylitis was scored as a swollen joint. An interdisciplinary group of physicians, nurses and patients considered that patients who receive DMARDs and/or biologic therapy who achieved 90% improvement of their outcome measures supported by no activity as shown on US assessment (both on Grey scale and Power Doppler examination) of the joints and enthesis sites and feel able to go back to work would be considered in remission and included in this work. Every patient completed a PROMs questionnaire at baseline and prior to every clinic visit [1]. Results 143 PsA patients were assessed in a multicenter study. Aiming for high specificity to reduce false positives, 5 domains were identified as core set criteria in PsA patients: Spine, Joints, Skin, Enthesis and functional disability. A patient is classified as achieving MDA when: Spine: ASDAS < 1.3; Joints: tender joint count ≤1 and swollen joint count ≤1; PASI ≤1 or BSA ≤3; Functional disability ≤0.5/3; tender entheseal points ≤1. Comparing the outcome measures of the cases who achieved MDA to their pre-treatment scores, revealed a significant difference (P<0.01) between the values for all of the domains. Individual regression analysis showed that all domains were predictors of MDA. Based on the mean cut-off points the suggested 5 domains achieved sensitivity 92%, specificity 96%. Conclusions Aiming for low levels of disease activity can improve the outcome of PsA patients. This study provides a global definition of an MDA “state” in PsA and defines a target for treatment. It is based on current expert opinion and patients and uses a composite of key outcome measures in PsA including US to encompass all of the domains of the disease. References El Miedany et al. Joint Bone Spine 2010; 77: 575-581 Disclosure of Interest None Declared