Dora Niedermayer

A patient-derived and patient-reported outcome measure for assessing psoriatic arthritis: elaboration and preliminary validation of the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire, a 13-country EULAR initiative

Introduction The objective was to develop a questionnaire that can be used to calculate a score reflecting the impact of psoriatic arthritis (PsA) from the patients’ perspective: the PsA Impact of Disease (PsAID) questionnaire. Methods Twelve patient research partners identified important domains (areas of health); 139 patients prioritised them according to importance. Numeric rating scale (NRS) questions were developed, one for each domain. To combine the domains into a single score, relative weights were determined based on the relative importance given by 474 patients with PsA. An international cross-sectional and longitudinal validation study was performed in 13 countries to examine correlations of the PsAID score with other PsA or generic disease measures. Test–retest reliability and responsiveness (3 months after a treatment change) were examined in two subsets of patients. Results Two PsAID questionnaires were developed with both physical and psychological domains: one for clinical practice (12 domains of health) and one for clinical trials (nine domains). Pain, fatigue and skin problems had the highest relative importance. The PsAID scores correlated well with patient global assessment (N=474, Spearman r=0.82–0.84), reliability was high in stable patients (N=88, intraclass correlation coefficient=0.94–0.95), and sensitivity to change was also acceptable (N=71, standardised response mean=0.90–0.91). Conclusions A questionnaire to assess the impact of PsA on patients’ lives has been developed and validated. Two versions of the questionnaire are available, one for clinical practice (PsAID-12) and one for clinical trials (PsAID-9). The PsAID questionnaires should allow better assessment of the patients perspective in PsA. Further validation is needed.

Ultrasound for enthesitis: handle with care!

Enthesitis, the inflammation involving the insertion of tendons, ligaments and joint capsule is a characteristic sign and hallmark of several rheumatic diseases in both adult and paediatric patients. The change in the perception of enthesitis (ie, its growing significance as a clinicopathological entity) is best reflected in the new European League Against Rheumatism (EULAR) recommendations for psoriatic arthritis, which recommend antitumour necrosis factor therapy for patients with active enthesitis and/or dactylitis and insufficient response to non-steroidal anti-inflammatory drugs or local steroid injections.1 It is also one of three entry criteria (the other two being arthritis and dactylitis) for the new Assessment of SpondyloArthritis Society classification criteria for peripheral spondylarthritis.2 Broadly, enthesitis can be evaluated either clinically or by one of several imaging modalities that have been validated to various extents for the assessment thereof. A recent systematic literature review that examined the US definition of enthesitis found large variability in the definitions utilised to outline enthesitis.3 Indeed, the appropriate definition of enthesitis and of its components remains an issue that is crucial for the evaluation of enthesitis with any given imaging modality. As of yet, we have no single examining modality that is capable of evaluating all of these components. Clinical examination may aid in the detection of enthesitis when palpation is used to trigger pain or tenderness. However, it only allows the detection of soft tissue swelling, including tendon thickening and accompanying bursitis, two key features of enthesitis, while failing to provide information on typical bony changes, ie, bone erosions, enthesophytes and calcifications. Clinical evaluation has been shown to underestimate enthesitis involvement compared with imaging modalities.3,–,6 Contrary to clinical evaluation, conventional radiography is useful for assessing bony changes, as described …

Contributions of ultrasound beyond clinical data in assessing inflammatory disease activity in rheumatoid arthritis: current insights and future prospects

Appropriate measures of disease activity need to be valid, reliable and sensitive to change for use in clinical studies while remaining at the same time feasible and practicable for utilization in daily clinical practice. Ultrasonography was shown to be a valid, sensitive and reliable imaging modality for the detection of synovitis in RA, however, it has so far failed to demonstrate superior sensitivity to change as compared with clinical examination. This review examines the current evidence for the use of established measures and/or US, either as an alternative or as a supplementary measure to clinical examination, as tools for monitoring synovitis in RA. It also includes a summary of results of recent studies evaluating clinical examination-based as well as clinical- and US-based multimodal disease activity indices. We review the rationale and limitations of incorporating US into composite disease activity indices and suggest a research roadmap for further studies in this field.

Relationship between radiographic joint space narrowing, sonographic cartilage thickness and anatomy in rheumatoid arthritis and control joints.

Objective To validate ultrasound (US) for measuring metacarpal cartilage thickness (MCT), by comparing it with anatomical measurement using cadaver specimens. To correlate US MCT with radiographic joint space narrowing (JSN) or width (JSW) in patients with rheumatoid arthritis (RA). Methods Bilateral metacarpophalangeal (MCP) joints of 35 consecutive outpatients, with recent hand X-rays, were included in the analysis. Metacarpal and phalangeal cartilage of MCP 2–5 was assessed bilaterally by US. JSW and JSN were evaluated on X-rays by the van der Heijde modified Sharp method (vdHS). In addition, cadaver specimens of MCP 2–5 joints (n=19) were evaluated by anatomical measurement and US. Results The agreement (intraclass correlation coefficient) between sonographic and anatomical MCT on cadaver specimens of MCP joints was 0.61. MCT of individual MCP joints correlated with individual MCP JSN (r=−0.32, p<0.001) and individual MCP JSW (r=0.72, p<0.001). No correlation was found between phalangeal cartilage thickness and JSN in individual MCP joints. The US MCT summary score for MCP joints 2–5 correlated with summary scores for JSW (r=0.78, p<0.001), JSN (r=−0.5, p<0.001), erosion score of the vdHS (r=−0.39, p<0.001) and total vdHS (r=−0.47, p<0.001). Conclusions Sonographic cartilage assessment in MCPs is closely related to anatomical cartilage thickness. Both JSW and JSN by radiography represent cartilage thickness in the MCP joints of patients with RA quite well. Thus, US is a valid tool for measuring MCT if radiographs are not available or in case of joint malalignment.

Determinants of patient-physician discordance in global assessment in psoriatic arthritis: a multicenter European study

Patient‐physician discordance in global assessment of disease activity concerns one‐third of patients, but what does it reflect? We aimed to assess patient‐physician discordance in psoriatic arthritis (PsA) and patient‐reported domains of health (physical and psychological) associated with discordance.

SAT0398 Fatigue in Psoriatic Arthritis is Related to Disease Activity Rather than to Demographic Characteristics – an Ancillary Analysis of the Cross-Sectional International PSAID Study of 246 Patients

Background Fatigue is an important aspect of disease for people suffering from psoriatic arthritis (PsA) (ref 1). However, little is known about the factors explaining fatigue in PsA. The causes of fatigue in inflammatory rheumatic diseases such as PsA, spondyloarthritis or rheumatoid arthritis are unclear; fatigue is diversely reported as being related either to patient characteristics, e.g., demographic, psychological and social factors, or to disease characteristics, e.g. disease activity. Objectives To evaluate the magnitude of fatigue in PsA and to assess if fatigue appears more strongly associated with patient- or with disease-related characteristics. Methods Patients: international cross-sectional study of unselected patients with a definite diagnosis of PsA according to the CASPAR criteria, in 13 countries [1]. Magnitude of fatigue was assessed by a numeric rating scale (range 0-10). Factors associated with high fatigue (>5/10) were assessed by multivariate logistic regression. The factors tested for association were patient related characteristics including demographic variables (age, gender, disease duration and country, education level); disease-related characteristics including articular activity (number of tender joints and number of swollen joints), skin activity (current psoriasis of more than 5% body surface); other activity (axial involvement, enthesitis, dactylitis, extra-articular involvement) and structural damage. Other patient reported outcomes including quality of life were not analysed since usually highly associated to fatigue. Results Data from 246 patients were analysed: mean age 51.2±13.0 yrs; N=119 (48.8%) males. Most had long-standing disease. Mean (±SD) fatigue was 5.0 (±3.0); 44.7% of patients had a fatigue level above 5 out of 10. High fatigue was well explained (AUC of the model, 0.73) by the following elements in multivariate analysis: higher skin activity (odds ratio, OR=4.7 [1.1; 20.7]), higher tender joint count (OR=1.1 [1.0; 1.1]) and lower education level (OR=0.9 [0.8; 1.0]). Conclusions Fatigue levels were high in this population of patients with PsA. High fatigue was explained mainly by disease activity rather than patient-related variables, indicating fatigue may be closely related to the disease process in PsA. Further studies are needed. References Gossec et al. PsAID study, EULAR 2013. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2309

SAT0490 Ultrasound is a Valid Tool for Measuring Measurement Metacarpal Cartilage Thickness and Correlates with Joint Space Narrowing and Joint Space Width on X-Ray in Patients with Rheumatoid Arthritis

Objectives To correlate cartilage thickness as measured by ultrasound (US) with joint space narrowing (JSN) and joint space width (JSW) as measured by conventional radiography in the metacarpophalangeal (MCP) joints of patients with rheumatoid arthritis. To validate US for measuring cartilage thickness, cadaver specimens of MCP joints were evaluated by US and by anatomical measurement. Methods Bilateral MCP 2-5 joints of 35 consecutive patients (280 joints) recruited in our outpatient clinic who had conventional radiographs (<1 years) of both hands available as well as cadaver specimens of MCP 2-5 joints (n:12) were included in the analysis. The cartilage layer of the metacarpal heads and proximal phalangeal bases 2-5 of included patients as well as of cadavers were assessed bilaterally using a 15 Mhz linear transducer (GE Logic E9) from dorsal longitudinal and transverse views in midline by 2 sonographers blinded to clinical/radiographic data. Cartilage thickness was measured in cm with an integrated caliper on static US images. Both JSW and JSN were evaluated on conventional posterior-anterior radiographs. JSW was quantified as the shortest distance betweenthe subchondral bone plates using a standard measurementtool, while JSN was evaluated using the van der Heijde modified Sharp scoring method (vdHS). Ankylosed and luxated joints were excluded from the analysis. Anatomical metacarpal cartilage thickness (MCT) was also evaluated on static digital images of fresh frozen cadaver specimens, split in the mid-sagittal plane. Cartilage thickness was correlated with x-ray findings using Spearman’s or Pearson’s correlation. Intra- and interobserver reliability of US, and agreement between US and anatomic measurements were assessed by estimating the intraclass correlation coefficient (ICC). Results In the patient population mean age was 63.1±11.3 years, mean disease duration was 10.6±7.8 years, mean CDAI was 8.1±7.3; 82.9% were female and 51% were rheumatoid factor positive. US measurement of MCT of MCP 2-5 was 0,42+/-0,19 mm. MCT of individual joints of the left and right hand correlated with individual MCP JSN (r=-0.799 and -0.702 respectively, p<0.01) and individual MCP JSW (r=0.588 and 0.401 respectively, p<0.01). The sum score of MCT for MCP joint 2-5 correlated with total MCP JSW (r=0.771, p<0.01), total JSN (r=-0.412, p<0.05), sum erosion score of the vdHS (r=-0.500, p<0.01) and the total vdHS (r=-0.576, p<0.01). No correlation was found between phalangeal cartilage thickness and JSN or JSW. Intra- and interobserver reliability of the US measurement of MCT in the clinical cohort and in the cadavers was 0.77 and 0.62, and 0.91 and 0.75 respectively. Agreement between US and anatomic measurement of MCT on cadaver specimens of MCP joints was 0.62. Conclusions Both JSW and JSN by radiography indeed represent cartilage thickness at least in MCP joints. US is a valid tool for measuring MCT. Phalangeal cartilage thickness has no added value beyond the measurement of MCT. When radiographic scoring is not available, US measurement of MCT might be a feasible alternative to depict cartilage damage in patients with RA. Disclosure of Interest None Declared