Angelika Lackner

Ultrasound composite scores for the assessment of inflammatory and structural pathologies in Psoriatic Arthritis (PsASon-Score)

IntroductionThis study was performed to develop ultrasound composite scores for the assessment of inflammatory and structural lesions in Psoriatic Arthritis (PsA).MethodsWe performed a prospective study on 83 PsA patients undergoing two study visits scheduled 6 months apart. B-mode and Power Doppler (PD) findings were semi-quantitatively scored at 68 joints (evaluating synovia, perisynovial tissue, tendons and bone) and 14 entheses. We constructed bilateral and unilateral (focusing the dominant site) ultrasound composite scores selecting relevant sites by a hierarchical approach. We tested convergent construct validity, reliability and feasibility of inflammatory and structural elements of the scores as well as sensitivity to change for inflammatory items.ResultsThe bilateral score (termed PsASon22) included 22 joints (6 metacarpophalangeal joints (MCPs), 4 proximal interphalangeal joints (PIPs) of hands (H-PIPs), 2 metatarsophalangeal joints (MTPs), 4 distal interphalangeal joints (DIPs) of hands (H-DIPs), 2 DIPs of feet (F-DIPs), 4 large joints) and 4 entheses (bilateral assessment of lateral epicondyle and distal patellar tendon). The unilateral score (PsASon13) compromised 13 joints (2 MCPs, 3 H-PIPs, 1 PIP of feet (F-PIP), 2 MTPs, 1 H-DIP and 2 F-DIPs and 2 large joints) and 2 entheses (unilateral lateral epicondyle and distal patellar tendon). Both composite scores revealed a moderate to high sensitivity (bilateral composite score 43% to 100%, unilateral 36% to 100%) to detect inflammatory and structural lesions compared to the 68-joint/14-entheses score. The inflammatory and structural components of the composite scores correlated weakly with clinical markers of disease activity (corrcoeffs 0 to 0.40) and the health assessment questionnaire (HAQ, corrcoeffs 0 to 0.39), respectively. Patients with active disease achieving remission at follow-up yielded greater reductions of ultrasound inflammatory scores than those with stable clinical activity (Cohen’s d effect size ranging from 0 to 0.79). Inter-rater reliability of bi- and unilateral composite scores was moderate to good with ICCs ranging from 0.42 to 0.96 and from 0.36 to 0.71, respectively for inflammatory and structural sub-scores. The PsASon22 and PsASon13 required 16 to 26 and 9 to 13 minutes, respectively to be completed.ConclusionBoth new PsA ultrasound composite scores (PsASon22 and PsASon13) revealed sufficient convergent construct validity, sensitivity to change, reliability and feasibility.

Real-time sonoelastography of salivary glands for diagnosis and functional assessment of primary Sjögren's syndrome.

The purpose of this study was to investigate the value of real-time sonoelastography (RTS) of salivary glands for the diagnosis and assessment of glandular damage in primary Sjögrens syndrome (pSS). After institutional review board approval, 45 pSS patients, 24 sicca patients and 11 healthy controls were investigated prospectively. Questionnaires were completed and Saxon and Schirmer tests and routine blood tests carried out in all patients. All patients underwent B-mode ultrasonography and RTS of parotid and submandibular glands. Abnormal findings were graded from 0 to 48 and from 0 to 16, respectively. Sialoscintigraphy was done according to a routine protocol; scoring ranged from 0 to 12. Statistical analysis comprised receiver operating characteristic curve and multivariate regression analysis. Patients with pSS had higher B-mode (median score = 25 [range: 2-44] vs. 9 [1-20], p < 0.001) and RTS (6.5 [2-13] versus 4 [1-9], p < 0.001) scores than controls with sicca syndrome, yielding areas under the curve of 0.83 and 0.85 (p < 0.05 each), respectively for pSS diagnosis. In cases with an inconclusive B-mode ultrasonography result, RTS (cutoff score: ≥ 6) led to a sensitive (66.7%) and specific (85.7%) classification of patients and sicca controls. In multivariate regression analysis, RTS (regression coefficient = -0.48, p = 0.005), but not B-mode ultrasonography, reflected impaired salivary gland function according to the Saxon test, whereas none of the subjective measures of dryness or discomfort were related to ultrasonography results. B-mode and RTS results were both associated with sialoscintigraphy scores (regression coefficient = 0.66, p < 0.001, and regression coefficient = 0.55, p = 0.001, respectively). Reproducibility of B-mode ultrasonography and RTS was good, with intra-class correlation coefficients of 0.93 (95% confidence interval: 0.57-0.98) and 0.93 (95% confidence interval: 0.79-0.98), respectively. In summary, RTS might be a useful adjunct to B-mode ultrasonography for diagnosis and assessment of salivary gland impairment in primary Sjögrens syndrome.

It’s more than dryness and fatigue: The patient perspective on health-related quality of life in Primary Sjögren’s Syndrome - A qualitative study

Objectives In Primary Sjögren’s Syndrome (PSS), there is an apparent lack of data concerning the perspectives of patients, their needs, preferences and difficulties of daily life. This qualitative study was conducted to explore perspectives and needs of patients with PSS that influence health related quality of life (HRQL). Methods We recruited 20 PSS patients fulfilling the American-European consensus classification criteria out of the PSS cohort of the Medical University Graz, Austria. In total, 6 focus group sessions (with three to four patients per group) were performed. A modified meaning condensation procedure was used to analyse the data. Results The interview analysis resulted in 484 meaning units, 254 subconcepts and 86 concepts. The identified concepts were grouped into three dimensions: physical dimension, psychological & emotional challenges and social life & daily living. A dependency between the three categories was identified. The concepts most commonly reported by patients were related to the physical dimension: pain and dryness as well as complaints associated with/provoked by these symptoms. Patients also reported shortness of breath, fatigue und constipation. Conclusions This qualitative study underpins that HRQL in PSS patients is affected by several factors. The problems are not limited to dryness, pain and fatigue while the complaints secondary to these symptoms are important to patients with PSS significantly affecting physical, psychological and social life components of HRQL. A disease-specific patient related outcome measures for clinical practice and trials should be developed considering the different aspects of HRQL in PSS.

Rheumatology Workforce Planning in Western Countries: A Systematic Literature Review

To compare health care planning models forecasting rheumatology workforce requirements in western countries.

Joint positions matter for ultrasound examination of RA patients-increased power Doppler signal in neutral versus flat position of hands.

Objective Position of joints might influence the result of US examination in patients with RA. The purpose of this work was to compare grey-scale (GS) and power Doppler (PWD) findings obtained in neutral vs flat position of hands. Methods A cross-sectional study of 42 RA patients with active disease. Two dimensional and 3D sonography of wrists and MCP joints were conducted in two different joint positions: neutral position, which is a slight flexion of the fingers with relaxed extensor muscles; and flat position, where all palm and volar sides of fingers touch the Table. Two dimensional GS synovitis (GSS) and PWD signals were scored semi-quantitatively (0-3). For 3D sonography, the percentage of PWD voxels within a region of interest was calculated. GSS was not quantified using 3D sonography. Results Compared with neutral position, 2D PWD signals disappeared in 28.3% of joints upon flattening. The median global 2D PWD score (sum of all PWD scores of an individual patient) decreased from 8 to 3 ( P < 0.001), and the global 3D PWD voxel score from 3.8 to 0.9 ( P < 0.001). The reduction of PWD scores was similar in all joints (2D: minus 50%, 3D: minus 66.4-80.1%). Inter- and intrareader agreement of PWD results was good (intraclass correlation coefficient: 0.75-0.82). Conclusion In RA, a neutral position of the hands is linked to a higher sensitivity of 2D and 3D sonography in detecting PWD signals at wrists and MCP joints, compared with a flat position. Standardization of the scanning procedure is essential for obtaining comparable US results in RA patients in trials and clinical routines.

Ultrasound verified inflammation and structural damage in patients with hereditary haemochromatosis-related arthropathy

BackgroundChronic arthropathy occurs in approximately two thirds of patients with hereditary haemochromatosis (HH). The aim was to study inflammatory and structural lesions in patients with HH with (HH-A) and without arthropathy (HH-WA) using ultrasonography.MethodsThis was a cross-sectional study of 26 patients with HH-A, 24 with HH-WA and 37 with hand osteoarthritis (HOA). Clinical examination was performed in 68 joints, and we retrieved data on hand function, pain and global disease activity (all using a visual analogue scale (VAS)), morning stiffness and ferritin levels. Standard x-ray and ultrasound were conducted in 36 joints (hands, hips, knees and ankles), and we graded grey scale synovitis (GSS), power Doppler ultrasound (PD), osteophytes, erosions, tenosynovitis and cartilage damage semi-quantitatively in accordance with prior publications.ResultsUltrasound revealed a high proportion of inflammatory changes in HH-A; GSS was found in 96.2% and PD signals in 80.8% of patients (median GSS score 9, PD score 2.5). The frequency of these findings was similar in HOA. Inflammation was also common in HH-WA, yielding GSS in 83.3% and PD signals in 50.0% of patients. Cartilage damage was most prominent in HH-A as compared to HH-WA and HOA (median scores 11.0, 2.5 and 2.0, respectively). The prevalence and extent of erosions and osteophytes were similar in all groups. None of the ultrasound scores was associated with pain or function; GSS, PD, osteophyte and cartilage scores correlated with x-ray-verified structural damage.ConclusionA high prevalence of ultrasound-verified inflammation and cartilage damage was found in HH-A, and to a lesser extent in HH-WA. These findings were associated with x-ray-verified damage but not with clinical scores of pain and function.

OP0181 Patient perspectives of people with primary sjÖgren’s syndrome: a multicentre qualitative european study

Background Primary Sjögren’s syndrome (pSS) is one of the most common systemic autoimmune disorders and leads to an impaired health related quality of life. However, treatment mainly focuses on the management of physical manifestations. Little is known about the lived experiences of people with pSS, including the impact on people’s life, functioning and their social relationships. Objectives To explore the perspectives of people with pSS from different European countries with various cultural backgrounds in order to achieve a broad understanding of concepts that are important and meaningful to people with pSS. This study is a part of a project which aims to evaluate the coverage of the patient perspectives by patient reported outcome measures in pSS, which is funded by the Austrian Association of Rheumatology. Methods A multicentre focus group study was performed in five European countries, namely Austria, Germany, Italy, Romania and Sweden. Patients were recruited from the outpatient clinics of the local centres. Focus groups were chaired by a trained moderator and followed an interview guide which included questions about impairments and limitations in body structures, body functions, activities and participation as well as contextual factors and resources, such as coping strategies. Focus groups were audiotaped and transcribed. We conducted a content-analysis of each focus group and subsequently combined the extracted concepts from each country, using the International Classification of Functioning, Disability and Health as a frame of reference. Results A total of 12 focus groups was conducted in seven participating centres in five countries. Fifty people (48 women; 96%) with pSS participated in the focus groups (ranging from two to four groups per country). All focus groups had a total duration of 1030 min and resulted in 252 pages of transcript. From qualitative analysis we derived concepts meaningful to people with pSS from all countries, especially those concepts that were linked to a physical dimension. However, we identified differences in the description of these experiences in daily life, for example for pain-concerning sensations or for the impact on social relationships. Furthermore, the attitudes towards the treatment and towards the disease differed between the participants. People with pSS had various coping strategies, such as gaining more knowledge about the disease or utilising non-pharmacological treatment. Conclusions This is the first multicentre qualitative European study which investigated the patient perspectives in pSS with a cross-cultural understanding. Clinicans, health professionals and researchers need to know about the perspectives, experiences and needs of people with pSS in order to ensure a comprehensive treatment. Disclosure of Interest None declared

SAT0628 High Prevalence of Ultrasound Verified Enthesitis in Patients with Inflammatory Bowel Disease with or Without Spondylarthritis

Background Inflammatory bowel disease (IBD) is closely associated with spondylarthritis (SpA). Enthesitis is an important feature of SpA but may be clinically silent in a high proportion of patients. Objectives The aim of this study was to compare the prevalence of ultrasound (US) verified enthesitis in IBD patients with and without SpA, patients with irritable bowel syndrome (IBS) and healthy controls (HC). Methods We prospectively recruited IBD patients with or without SpA, patients with IBS and HC. Clinical assessments included demographics, comorbidities, IBD symptoms, BMI, sport activities and a musculoskeletal clinical examination. Ultrasound examination was performed by 1 of 2 independent investigators, blinded to clinical results, at 12 entheses: bilaterally triceps, lateral epicondyles, distal insertion of quadriceps, proximal and distal insertion of patellar tendon, distal insertion of Achilles tendon and plantar fascia using an Esaote MyLab Twice ultrasound device with 18-MHz linear transducer. The following abnormalities were scored according to the Madrid Ankylosing Spondylitis Enthesitis Index (MASEI), and the Glasgow Ultrasound Enthesitis Scoring System (GUSS) as appropriate: Power Doppler (PD) changes, enthesophytes, erosions, enthesal thickening, bursitis and structural abnormalities. Statistical analysis was performed using SPSS v22 and we used the Mann Whitney U test and the Chi square test for comparisons. Inter-reader agreement between ultrasound investigators was tested using the Intra-class correlation coefficient (ICC). Results We included 33 IBD patients without SpA [66.7% male; median age 44 years (range 19-62), median ESR 9mm/h (range 1-45), CRP 3.5 mg/l (0.6-39.2), anti-TNF therapy in 45.5%], 14 IBD patients with SpA [71.4% male, age 45 years (21-56), ESR 10mm/h (3-25), CRP 3.0mg/l (0.1-41.0), anti-TNF therapy in 71.4%], 26 IBS patients [26.9% male (p<0.05 compared to IBD patients without or with SpA), age 41 (18-65)] and 18 HC [27.8% male (p<0.05 compared to IBD patients without or with SpA), age 43 (21-58)]. Higher MASEI scores were found in patients with IBD without SpA [median 21.0 range (8.0-53.0)] and IBD associated SpA [33.0 (8-50)] than in IBS patients [10.5 (0-42.0)-p<0.001 for both comparison] and HC [12.0 (2.0-38.0)-p<0.01 for both comparisons]. Similar results were observed for the GUSS scores. Enthesophyte subscores were highest in IBD patients with SpA [median 11.5 (range 0-26.0)] as compared to IBD without SpA [7 (2-28)], IBS [5 (0-25)] and HC groups [6.5 (0-21), p<0.05 for all comparisons]. Positive PD was more commonly observed in patients with IBD without SpA [n=22 (66.7%)] and IBD with SpA [n=9 (64.3%)] compared to IBS patients [n=5 (19. 2%)] and HC [n=4 (22.2%), p<0.05 for all comparisons]. Erosion were more common in patient with IBD without SpA [18 (54.5%)], IBD with SpA [11 (78. 6%)] and IBS patienta [10 (38. 5%)] compared to HC [2 (11. 1%), p<0.05 for all comparisons]. No association was found between US results and clinical variables. The intra-reader agreement was good [ICC 0.89 (0.52 to 0.98)]. Conclusions Ultrasound verified enthesitis is more common in patients with IBD with or without SpA as compared to patients with IBS or HC. Disclosure of Interest None declared

SAT0170 Ultrasound Composite Score for the Assessment of Inflammatory and Structural Pathologies in Psoriatic Arthritis

Background In clinical trials and routine practice of Psoriatic arthritis (PsA), disease activity is still monitored by RA specific clinical composites even if these measures are of questionable value for the assessment of PsA because of the heterogeneous nature of the disease affecting articular and extraarticular sites. (1) Objectives To develop ultrasound composite score(s) for the assessment of joint, peri-articular and enthesal pathologies in Psoriatic Arthritis (PsA). Methods Prospective study on 83 PsA patients with two study visits scheduled 6 months apart. B-mode and Power Doppler (PD-) findings were semiquantitatively scored at 68 joints (evaluating synovia, peritendinous tissue, tendons and bony changes) and 14 entheses. We used a hierarchical approach to construct a bilateral and a unilateral (focusing the dominant site) ultrasound composite scores. Discriminatory, internal and external validity, sensitivity, reliability and feasibility of the scores were tested. Results The bilateral score includes wrists, 2nd, 3rd, 5th metacarpophalangeal (MCP) joints, 2nd, 3rd proximal (PIP) and distal (DIP) interphalangeal joints, knees, 1st metatarsophaangal (MTP) and 3rd DIP joints of feet (F-DIP), lateral epicondyles and distal patellar tendons. The unilateral score compromises wrist, 2nd, 5th MCPs, 1st, 2nd, 3rd PIPs, 2nd DIP, knee, 1st,5th MTP, 1st F-PIP, 2nd, 3rd F-DIP, lateral epicondyle and distal patellar tendon of the dominant site. Both scores revealed a moderate to high sensitivity (bilateral composite 42-100%, unilateral 36-100%) to detect inflammatory and structural lesions. Data correlated with results from 68-joint/14-entheses score (corrcoeffs 0.39-1.0) and with clinical parameters (corrcoeffs 0-0.41). Patients achieving remission yielded greater reductions of ultrasound verified inflammation than patients did with stable clinical activity. Conclusions We propose two new ultrasound composite scores for assessment of inflammatory and structural lesions in PsA. Both scores revealed discriminatory, internal and external validity, reliability and feasibility. References Smolen JS, Braun J, Dougados M et al. Treating spondyloarthritis, including ankylosing spondylitis and psoriatic arthritis, to target: recommendations of an international task force. Ann Rheum Dis. 2014 Jan;73(1):6-16. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5188