Antonella Draghessi

Ultrasound in psoriatic arthritis. Can it facilitate a best routine practice in the diagnosis and management of psoriatic arthritis

Important advances from both therapeutic and clinical assessment have recently been reported in psoriatic arthritis (PsA). Moreover, the constant challenge to provide a more comprehensive assessment of this heterogeneous disease results in a variety of clinical instruments that help the clinician for a global evaluation of both disease activity and responsiveness. The current European League Against Rheumatism (EULAR) recommendations on the use of imaging suggest the use of ultrasound (US) in chronic arthritis to increase the diagnostic accuracy and improvement of its management as compared to clinical examination alone. Although US findings are not firmly established in daily clinical practice, it demonstrated several positive aspects such as good sensitivity and specificity, acceptable reliability, and adequate sensitivity to change, especially in the peripheral PsA. Additionally, recent works introduced the role of US in the assessment of skin and nails opening interesting area of research. The aim of this paper is to describe the potential role of US in the assessment of PsA and to discuss the current evidence supporting its application in daily clinical practice.

Ultrasound-detected tenosynovitis independently associates with patient-reported flare in patients with rheumatoid arthritis in clinical remission: results from the observational study STARTER of the Italian Society for Rheumatology

OBJECTIVES This study aimed to estimate the prevalence of US-detected tenosynovitis in RA patients in clinical remission and to explore its clinical correlates. METHODS A total of 427 RA patients in clinical remission were consecutively enrolled from 25 Italian rheumatology centres. Tenosynovitis and synovitis were scored by US grey scale (GS) and power Doppler (PD) semi-quantitative scoring systems at wrist and hand joints. Complete clinical assessment was performed by rheumatologists blinded to the US results. A flare questionnaire was used to assess unstable remission (primary outcome), HAQ for functional disability and radiographic erosions for damage (secondary outcomes). Cross-sectional relationships between the presence of each US finding and outcome variables are presented as odds ratios (ORs) and 95% CIs, both crude and adjusted for pre-specified confounders. RESULTS The prevalence of tenosynovitis in clinical remission was 52.5% (95% CI 0.48, 0.57) for GS and 22.7% (95% CI 0.19, 0.27) for PD, while the prevalence of synovitis was 71.6% (95% CI 0.67, 0.76) for GS and 42% (95% CI 0.37, 0.47) for PD. Among clinical correlates, PD tenosynovitis associated with lower remission duration and morning stiffness while PD synovitis did not. Only PD tenosynovitis showed a significant association with the flare questionnaire [OR 1.95 (95% CI 1.17, 3.26)]. No cross-sectional associations were found with the HAQ. The presence of radiographic erosions associated with GS and PD synovitis but not with tenosynovitis. CONCLUSIONS US-detected tenosynovitis is a frequent finding in RA patients in clinical remission and associates with unstable remission.

Ultrasound in systemic sclerosis. A multi-target approach from joint to lung

Ultrasound (US) is a cost-effective, noninvasive, accessible imaging modality that clinicians use at the point of care to assess disease activity and therapeutic efficacy in different rheumatic conditions. However, its utility has been prevalently demonstrated in the field of chronic arthritides. Only in the last few years there was an interest to explore the potential of US beyond the musculoskeletal area. In this way, preliminary US data about the assessment of the different targets involved in systemic sclerosis such as joints, tendons, skin, vessels, and lung have been provided. The main purpose of this US review is to provide an overview of the potential role of US in the multi-target assessment of SSc and to discuss the current evidence supporting its relevance and applications in daily clinical practice.

Identifying the symptom and functional domains in patients with fibromyalgia: results of a cross-sectional Internet-based survey in Italy

Objective The aims of this cross-sectional study were to investigate the usefulness of using an Internet survey of patients with fibromyalgia in order to obtain information concerning symptoms and functionality and identify clusters of clinical features that can distinguish patient subsets. Methods An Internet website has been used to collect data. Fibromyalgia Impact Questionnaire Revised version, self-administered Fibromyalgia Activity Score, and Self-Administered Pain Scale were used as questionnaires. Hierarchical agglomerative clustering was applied to the data obtained in order to identify symptoms and functional-based subgroups. Results Three hundred and fifty-three patients completed the study (85.3% women). The highest scored items were those related to sleep quality, fatigue/energy, pain, stiffness, degree of tenderness, balance problems, and environmental sensitivity. A high proportion of patients reported pain in the neck (81.4%), upper back (70.1%), and lower back (83.2%). A three-cluster solution best fitted the data. The variables were significantly different (P<0.0001) among the three clusters: cluster 1 (117 patients) reflected the lowest average scores across all symptoms, cluster 3 (116 patients) the highest scores, and cluster 2 (120 patients) captured moderate symptom levels, with low depression and anxiety. Conclusion Three subgroups of fibromyalgia samples in a large cohort of patients have been identified by using an Internet survey. This approach could provide rationale to support the study of individualized clinical evaluation and may be used to identify optimal treatment strategies.

SAT0061 Concurrent Ultrasound-Detected Synovitis and Tenosynovitis Predict Flare in Patients with Rheumatoid Arthritis in Clinical Remission

Background Subclinical synovial inflammation detected by ultrasonography (US) in patients with rheumatoid arthritis (RA) in clinical remission relates to disease flare. The impact of tenosynovitis in this context is not known. Objectives To evaluate the association between US-detected tenosynovitis and synovitis in RA patients in clinical remission and flare over 12-months. Methods STARTER is a multicentre cohort study of the US Study Group of the Italian Society for Rheumatology. Participants were selected on the basis of a reliability exercise and the availability of high-end equipment. Patients with RA in clinical remission underwent clinical evaluation and US synovitis (-S) and tenosynovitis (-T) were assessed categorically for Grey Scale (GS) and power Doppler (PD) at 11 joints, extensor and flexor tendons in both hands and wrists. Patients were seen at 6 and 12 months. Flare within 12 months was defined as increase of >1.2 or >0.6 if final DAS28>3.2. The relationship between the presence of GS-T/-S, PD-T/-S was evaluated by logistic models, presented as odds ratios (OR) and 95% confidence interval (CI), adjusted for pre-specified confounders. Results 361 patients (72.3% f, mean age (sd) 56.1 (13.3), median disease duration (IQR) 7.1 years (3.6–13.5)) were included. 98/326 (30.6%) patients had a flare within 12 months. Considering US variables separately, only PD-S significantly predicted flare (OR 1.87 (1.12,3.14)). When the model included both –T and –S, only the concurrent presence of –T and –S predicted flare (PD-T+-S: OR 2.06 (1.04, 4.07); GS-T+-S: OR 2.27, (1.01,5.10)), while isolated –S and –T did not. Conclusions In patients with RA in clinical remission, US-detected synovial and tenosynovial inflammation identifies patients at risk of flare. US might help decisions on management in this population. Disclosure of Interest None declared

SAT0593 Ultrasonographic Evaluation of Joint Damage in Knee Osteoarthritis: A Comparison with Conventional Radiography

Background Conventional radiography is the most commonly used imaging modality for assessing osteoarthritis (OA) in daily practice. However, the sensitivity of conventional radiography for detecting early changes of cartilage damage may be relatively low. Ultrasonography (US) is able to visualize large portions of femoral hyaline cartilage directly and to assess osteophytes [1-3]. Objectives The main aim of this study was to compare US with conventional radiography for the assessment of joint damage in knee OA. Methods One hundred sixty-six knees of 84 patients (59 women and 25 men) with primary knee OA were included in this study. The femoral hyaline cartilage of the medial para-patellar aspect and osteophytes of both medial and lateral femoral condyle were scanned. The cartilage involvement and the osteophytes were both quantitatively (grade 0-3) and qualitatively assessed. An US global grade for knee joint damage was developed merging the US cartilage damage and osteophyte grades (grade 0-3). The US findings were compared with those obtained by conventional radiography using the Kellgren and Lawrence (K/L) grading system (grade 0-3). Results There was a moderate agreement between US cartilage damage grade and K/L grade assessments (weighted κ=0.466: 95% CI 0.361-0.572) and fair agreement between US osteophyte grade and K/L grade assessments (weighted κ =0.306: 95% CI 0.208-0.405). A fair agreement was found also between the US global grade and K/L grade assessments (weighted κ =0.396: 95% CI 0.289-0.504). In 31 knees with K/L grade 1, US grade higher than 1 were found in 6 knees for cartilage damage and 14 knees for osteophytes. Ninety-two percent of knees that had less than 1 mm cartilage thickness were classified as severe OA in radiographs. Conclusions The present study provides evidence supporting the concurrent validity of US in the assessment of knee joint damage due to OA through its agreement with conventional radiography. However, such a correlation was moderate. A possible reason explaining the discrepancy between radiographic and US assessment may be related to the fact that US allows a direct visualization of femoral cartilage while joint space width assessed by conventional radiography is the result of cartilage thinning and/or meniscal degeneration and protrusion. References Grassi W, Lamanna G, Farina A, Cervini C. Sonographic imaging of normal and osteoarthritic cartilage. Semin Arthritis Rheum 1999;28:398-403. Naredo E, Acebes C, Möller I, Canillas F, de Agustín JJ, de Miguel E, et al. Ultrasound validity in the measurement of knee cartilage thickness. Ann Rheum Dis 2009;68:1322-7. Saarakkala S, Waris P, Waris V, Tarkiainen I, Karvanen E, Aarnio J, et al. Diagnostic performance of knee ultrasonography for detecting degenerative changes of articular cartilage. Osteoarthritis Cartilage 2012;20:376-81. Disclosure of Interest None declared

The predictive role of ultrasound-detected tenosynovitis and joint synovitis for flare in patients with rheumatoid arthritis in stable remission. Results of an Italian multicentre study of the Italian Society for Rheumatology Group for Ultrasound: the STARTER study

Objective To define the role of ultrasound (US) for the assessment of patients with rheumatoid arthritis (RA) in clinical remission, including joint and tendon evaluation. Methods A multicentre longitudinal study has been promoted by the US Study Group of the Italian Society for Rheumatology. 25 Italian centres participated, enrolling consecutive patients with RA in clinical remission. All patients underwent complete clinical assessment (demographic data, disease characteristics, laboratory exams, clinical assessment of 28 joints and patient/physician-reported outcomes) and Power Doppler (PD) US evaluation of wrist, metacarpalphalangeal joints, proximal interphalangeal joints and synovial tendons of the hands and wrists at enrolment, 6 and 12 months. The association between clinical and US variables with flare, disability and radiographic progression was evaluated by univariable and adjusted logistic regression models. Results 361 patients were enrolled, the mean age was 56.20 (±13.31) years and 261 were women, with a mean disease duration of 9.75 (±8.07) years. In the 12 months follow-up, 98/326 (30.1%) patients presented a disease flare. The concurrent presence of PD positive tenosynovitis and joint synovitis predicted disease flare, with an OR (95% CI) of 2.75 (1.45 to 5.20) in crude analyses and 2.09 (1.06 to 4.13) in adjusted analyses. US variables did not predict the worsening of function or radiographic progression. US was able to predict flare at 12 months but not at 6 months. Conclusions PD positivity in tendons and joints is an independent risk factor of flare in patients with RA in clinical remission. Musculoskeletal ultrasound evaluation is a valuable tool to monitor and help decision making in patients with RA in clinical remission.

THU0121 Ultrasound in the assessment of carpal tunnel syndrome in patients with rheumatoid arthritis

Background Carpal tunnel syndrome (CTS) is one of the most frequent extra-articular manifestations of rheumatoid arthritis (RA). Ultrasound (US) has proven to represent a reliable tool for the diagnosis of CTS [1]. However, its role in the diagnosis of CTS in patients with RA has been poorly investigated. Objectives The aim of this study is to evaluate the US findings at carpal tunnel level in a cohort of patients with RA, focusing on those with a clinical diagnosis of CTS. Methods Patients with RA fulfilling the ACR/EULAR 2010 classification criteria were consecutively enrolled. The diagnosis of CTS was made according to the American Academy of Neurology practice parameter for CTS [2]. The MSUS assessment was carried out using a MyLab Twice (Esaote SPA) US system working with a 18–22 MHz linear probe. The power Doppler (PD) frequency was set between 7.5 and 11.3 MHz. The following grey scale (GS) US parameters were assessed at the carpal tunnel level: cross-sectional area (CSA) of the median nerve at the carpal tunnel inlet (at the level of the pisiform and scaphoid bones), presence of flexor tenosynovitis and palmar radio-carpal synovitis (both in GS and PD), presence of crystal macro-aggregates and marked bone profile irregularities. The median nerve was considered enlarged if its CSA was more than 12 mm2. We evaluated the presence of intra-neural PD signals at the carpal inlet and scored its entity (0=no PD signal, 1=one single vessel within median nerve, 2=two or three single or two confluent vessels and 3=more than three single or more than two confluent vessels). PD was considered “positive” if grade 1 or more was found. Results We included 40 RA patients. CTS was diagnosed in 19 out of 80 wrists (23.8%) and in 13 out of 40 RA patients (32.5%). Enlarged median nerve was found in 3 out of 19 wrists with CTS (15.8%) and in 6 out of 61 wrists without CTS (9.8%). Flexor tenosynovitis was found in 7 out of 19 wrists with CTS (36.8%) and in 5 out of 61 wrists without CTS (8.2%). Palmar radio-carpal synovitis was found in 2 out of 19 wrists with CTS (10.5%) and in 3 out of 61 wrists without CTS (4.9%). Crystal macro-aggregates were not detected in any of the scanned wrists. Marked bone profile irregularities were found in 2 out of 19 wrists with CTS (10.5%) and in 14 out of 61 wrists without CTS (23%). Positive intra-neural PD was found in 9 out of 19 wrists with CTS (47.4%) and in 9 out of 61 wrists without CTS (14.7%). Conclusions These preliminary results suggest that MSUS could be a useful tool in the diagnosis of CTS also in patients with RA. Intra-neural PD and flexor tenosynovitis were the most frequently MSUS abnormalities detected in RA patients with CTS. The inflammatory involvement of the tendinous and joint structures which are part of the carpal tunnel could lead to median nerve compression and CTS symptoms and should be considered in the MSUS assessment of CTS. References McDonagh C, Alexander M, Kane D. The role of ultrasound in the diagnosis and managment of carpal tunnel sindrome: a new paradigme. Rheumatology (Oxford). 2015 Jan;54(1):9–19.doi: 10.1093/rheumatology/keu275. Practice parameters for carpal tunnel syndrome (summary statement). Report of the quality standards subcommittee of the American Academy of Neurology. Neurology 1993;43:2406–9. Disclosure of Interest None declared

Erratum to: Hidden musculoskeletal involvement in inflammatory bowel disease: a multicenter ultrasound study

Author details Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Praceta Prof Mota Pinto, Coimbra 3000-075, Portugal. Rheumatology Unit, L. Sacco University Hospital, Milan, Italy. Clinica Reumatologica, Università Politecnica delle Marche, Jesi, Ancona, Italy. Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal. Division of Musculoskeletal and Rheumatic diseases, National Institute of Rehabilitation, Mexico city, Mexico.

SAT0547 Ultrasound Assessment of Cartilage Damage at Metacarpal Head Level in Rheumatoid Arthritis and Osteoarthritis

Background Ultrasound (US) with very high frequency probe (up to 22 MHz) has a resolution power of 0.1 mm and allows for the direct visualization of the hyaline cartilage of the metacarpal head. Objectives To determine the prevalence and distribution of US-detected cartilage damage at metacarpal heads of patients with rheumatoid arthritis (RA) and osteoarthritis (OA) and to investigate if cartilage damage evaluated by US method is associated with radiographic scores (Sharp van der Heijde score and Simple Erosion Narrowing Score (SENS) in RA and Kallman score in OA). Methods 50 patients with RA and 19 patients with OA were enrolled in this study. The US examination of the metacarpal head cartilage from II to V finger of both hands was performed. 400 metacarpophalangeal (MCP) joints in RA and 152 MCP joints in OA were scanned with a very high-frequency linear probe (i.e. 10–22 MHz), using a previously described scoring system for cartilage damage1. In a subgroup of 27 patients with RA and 7 with OA the radiographic scores were calculated. Pearsons correlation coefficient and Cohen κ were used to investigate associations between US and radiographic scores. Results The US examination of the metacarpal head cartilage from II to V finger of both hands lasted a mean of 6 minutes. The metacarpal head cartilage was found positive for cartilage damage by US in 139 out of 400 (34.8%) MCP joints in RA and in 65 out of 152 (42.8%) MCP joints in OA. In RA, the hyaline cartilage of the II right metacarpal head was the most frequently affected followed by the II left and the III right metacarpal head. The less affected was the V metacarpal head bilaterally. In OA, cartilage damage was homogeneously distributed in all MCP joints. Symmetric damage of cartilage was observed in 97/400 (24.3%) RA joints and in 44/152 (28.9%) OA joints. Conversely, asymmetric damage of the cartilage was observed in 42/400 (10.5%) RA joints (only in patients with disease duration more than 2 years) and in 21/152 (13.8%) joints in OA. A significant positive correlation was found between US total score and either Sharp van der Heijde score or SENS score (r=0.584, p<0.001; r=0.510, p<0.001, respectively) in RA and between US total score and Kallman score (r=0.687, p<0.001) in OA. Agreement between two imaging methods was high, 78% in RA (κ=0.570, p<0.001) and in 91% in OA (κ=0.750, p<0.001). Conclusions The present study provides evidence supporting the feasibility of the US assessment of the metacarpal head cartilage. A positive significant correlation was found between the US findings, obtained with a very high frequency probe by an experienced sonographer and the radiographic scores assigned by an expert radiologist. References Filippucci E et al: Interobserver reliability of ultrasonography in the assessment of cartilage damage in rheumatoid arthritis. Ann Rheum Dis 2010, 69(10), p. 1845–1848. Acknowledgement Supported by EULAR, IGA grant No. NT12437 and GAUK grant No. 1010213. Disclosure of Interest None declared