Judith Gretler

Disparity between ultrasound and clinical findings in psoriatic arthritis

Objective To investigate the association between psoriatic arthritis (PsA)-specific clinical composite scores and ultrasound-verified pathology as well as comparison of clinical and ultrasound definitions of remission. Methods We performed a prospective study on 70 consecutive PsA patients. Clinical assessments included components of Disease Activity Index for Psoriatic Arthritis (DAPSA) and the Composite Psoriatic Disease Activity Index (CPDAI). Minimal disease activity (MDA) and the following remission criteria were applied: CPDAI joint, entheses and dactylitis domains (CPDAI-JED)=0, DAPSA≤3.3, Booleans remission definition and physician-judged remission (rem-phys). B-mode and power Doppler (PD-) ultrasound findings were semiquantitatively scored at 68 joints (evaluating synovia, peritendinous tissue, tendons and bony changes) and 14 entheses. Ultrasound remission and minimal ultrasound disease activity (MUDA) were defined as PD-score=0 and PD-score ≤1, respectively, at joints, peritendinous tissue, tendons and entheses. Results DAPSA but not CPDAI correlated with B-mode and PD-synovitis. Ultrasound signs of enthesitis, dactylitis, tenosynovitis and perisynovitis were not linked with clinical composites. Clinical remission or MDA was observed in 15.7% to 47.1% of PsA patients. Ultrasound remission and MUDA were present in 4.3% and 20.0% of patients, respectively. Joint and tendon-related PD-scores were higher in patients with active versus inactive disease according to CPDAI-JED, DAPSA, Booleans and rem-phys, whereas no difference was observed regarding enthesitis and perisynovitis. DAPSA≤3.3 (OR 3.9, p=0.049) and Booleans definition (OR 4.6, p=0.03) were more useful to predict MUDA than other remission criteria. Conclusions PsA-specific composite scores partially reflect ultrasound findings. DAPSA and Booleans remission definitions better identify MUDA patients than other clinical criteria.

Anticardiolipin antibodies in rheumatoid arthritis: their relation to rheumatoid nodules and cutaneous vascular manifestations

One hundred and seventy‐three consecutive patients with rheumatoid arthritis were examined for the presence of anticardiolipin antibodies (ACA), and for the clinical relevance and the relation of these antibodies to skin manifestations. Abnormally elevated IgG‐ and/or IgM‐ACA levels were detected by an enzyme‐linked immunosorbent assay in the sera of 55 (32%) patients. There was no statistical evidence of an association between ACA and a history of thrombosis in these patients. However, ACA were statistically significantly linked to the presence of rheumatoid nodules, which were found in 36 (21%) patients. In three patients, ACA were associated with vascular manifestations, including livedo reticularis, thrombophlebitis, and leucocytoclastic vasculitis. Our findings suggest that, although a subset of ACA may be linked to cutaneous vascular conditions, the major fraction of ACA in rheumatoid arthritis may have a different specificity than in other diseases, in which ACA are often linked to thrombotic events.

Ultrasound for diagnosis of carpal tunnel syndrome: comparison of different methods to determine median nerve volume and value of power Doppler sonography

Objective To compare ultrasound measurement of median nerve cross-sectional area (CSA) at different anatomical landmarks and to assess the value of power Doppler signals within the median nerve for diagnosis of carpal tunnel syndrome (CTS). Methods A prospective study of 135 consecutive patients with suspected CTS undergoing two visits within 3 months. A final diagnosis of CTS was established by clinical and electrophysiological findings. CSA was sonographically measured at five different levels at forearm and wrist; and CSA wrist to forearm ratios or differences were calculated. Intraneural power Doppler signals were semiquantitatively graded. Diagnostic values of different ultrasound methods were compared by receiver operating characteristic curves using SPSS. Results CTS was diagnosed in 111 (45.5%) wrists; 84 (34.4%) had no CTS and 49 (20.1%) were possible CTS cases. Diagnostic values were comparable for all sonographic methods to determine median nerve swelling, with area under the curves ranging from 0.75 to 0.85. Thresholds of 9.8 and 13.8 mm2 for the largest CSA of the median nerve yielded a sensitivity of 92% and a specificity of 92%. A power Doppler score of 2 or greater had a specificity of 90% for the diagnosis of CTS. Sonographic median nerve volumetry revealed a good reliability with an intraclass correlation coefficient of 0.90 (95% CI 0.79 to 0.95). Conclusions Sonographic assessment of median nerve swelling and vascularity allows for a reliable diagnosis of CTS. Determination of CSA at its maximal shape offers an easily reproducible tool for CTS classification in daily clinical practice.

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.

Sternoclavicular septic arthritis: A rare but serious complication of subclavian venous catheterization

SummarySternoclavicular septic arthritis is a rare complication of subclavian venous catheterization. We estimate that septic involvement of this joint may be as common as one in 500 catheterizations. We report two patients with insidious onset of shoulder pain, chest discomfort, low-grade fever and slight but painful swelling of a sternoclavicular joint four weeks following subclavian venous catheterization. Positive blood cultures in the presence of abnormal bone scan and abnormal conventional X-ray examination or computed tomography of the sternoclavicular joint led to the diagnosis of septic arthritis. Both patients responded well to antibiotic treatment. Based on our observations and that reported in the literature, the earliest changes of sternoclavicular septic arthritis may be detected by bone scan while plain X-ray studies and CT become abnormal during advanced stages of this type of arthritis. We would like to alert physicians to this cause of fever and joint pain in patients who previously underwent subclavian venous catheterization.

The Value of Median Nerve Sonography as a Predictor for Short- and Long-Term Clinical Outcomes in Patients with Carpal Tunnel Syndrome: A Prospective Long-Term Follow-Up Study

Objectives To investigate the prognostic value of B-mode and Power Doppler (PD) ultrasound of the median nerve for the short- and long-term clinical outcomes of patients with carpal tunnel syndrome (CTS). Methods Prospective study of 135 patients with suspected CTS seen 3 times: at baseline, then at short-term (3 months) and long-term (15–36 months) follow-up. At baseline, the cross-sectional area (CSA) of the median nerve was measured with ultrasound at 4 levels on the forearm and wrist. PD signals were graded semi-quantitatively (0–3). Clinical outcomes were evaluated at each visit with the Boston Questionnaire (BQ) and the DASH Questionnaire, as well as visual analogue scales for the patient’s assessment of pain (painVAS) and physician’s global assessment (physVAS). The predictive values of baseline CSA and PD for clinical outcomes were determined with multivariate logistic regression models. Results Short-term and long-term follow-up data were available for 111 (82.2%) and 105 (77.8%) patients, respectively. There was a final diagnosis of CTS in 84 patients (125 wrists). Regression analysis revealed that the CSA, measured at the carpal tunnel inlet, predicted short-term clinical improvement according to BQ in CTS patients undergoing carpal tunnel surgery (OR 1.8, p = 0.05), but not in patients treated conservatively. Neither CSA nor PD assessments predicted short-term improvement of painVAS, physVAS or DASH, nor was any of the ultrasound parameters useful for the prediction of long-term clinical outcomes. Conclusions Ultrasound assessment of the median nerve at the carpal tunnel inlet may predict short-term clinical improvement in CTS patients undergoing carpal tunnel release, but long-term outcomes are unrelated to ultrasound findings.

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.

Response to: ‘Paying attention to carpal tunnel contents lesions: ultrasound for evaluation of carpal tunnel syndrome’ by zhu and Liu

Our and several previous studies demonstrated a high diagnostic value of ultrasound for carpal tunnel syndrome (CTS).1 ,2 Among the various abnormalities within the carpal tunnel reported, the increase of the cross-sectional area (CSA) of the median nerve is the most commonly studied ultrasound abnormality.3 Additionally, ultrasound allows the identification of secondary causes of CTS, such as synovitis, tenosynovitis, calcified masses or tophaceous gout, as pointed out by zhu et al. 4 We acknowledge that the diagnostic value of ultrasound is not perfect, as some patients may suffer from CTS despite a normal ultrasound result and, …

THU0399 The Ankylosing Spondylitis Disease Activity Index (ASDAS) To Assess Disease Activity in Psoriatic Arthritis: Table 1.

Background Psoriatic arthritis (PsA) belongs to the spondyloarthritides and disease activity can be evaluated by the Disease Activity Index for Psoriatic Arthritis (DAPSA) and the Composite Psoriatic Disease Activity Index (CPDAI) 1. The Ankylosing Spondylitis Disease Activity Score (ASDAS) is a composite disease activity score for ankylosing spondylitis covering peripheral involvement in both versions selected by ASAS international society (ASDASCRP and ASDASESR)2. Objectives To evaluate the possible importance of ASDASCRP and ASDASESR to assess disease activity in PsA. Methods In a cross-sectional study patients attending our outpatient clinic and fulfilling CASPAR criteria of PsA underwent a complete rheumatologic assessment to calculate the disease activity score CPDAI and DAPSA for PsA as well as the ASDASCRP and ASDASESR after informed consent was obtained. On the same day a rheumatologist unaware of the clinical status of the patients performed B-mode and power Doppler (PD) sonography of peripheral joints, of tendon sheets and entheses according to the MASEI, and of perisynovial tissue of finger joints. Results were graded semi-quantitatively and sum scores were calculated for PD signals and for pathological B-mode and PD findings together (GLUS, range 0–832). Descriptive statistics were used to summarise the data and correlations were analysed by the Spearmans rank correlation test. Results 67 of 84 included patients (49 male, 18 female; mean age 51 (SD 12) years; median disease duration 7 years (IQR 4–18) could be evaluated. We found a strong correlation of the DAPSA and CPDAI score and a low but significant correlation of the GLUS and the PD sum score with the ASDASESR and ASDASCRP (table). We observed only a moderate association of the DAPSA with the GLUS (r=0.52, 95%CI 0.32–0.68) and the association of the CPDAI with the GLUS and the PD sum score (r=0.25, 95%CI 0.003–0.47 and r=0.19, 95%CI -0.06–0.42, respectively) was even lower than the correlation of the GLUS and the PD sum score with the ASDASESR and the ASDASCRP. In PsA-patients with clinically defined remission 25.0% of the patients fulfilled the CPDAI and 29.1% the DAPSA remission criteria. However, in patients with clinically defined remission 50.0% and 54.2% fulfilled the ASDASESR and ASDASCRP criteria for inactive disease.Table 1. Correlation of the PsA composite and ultrasound scores with the ASDAS ASDASCRP (r, 95% CI) ASDASESR (r, 95% CI) CPDAI 0.67 (0.51–0.79)*** 0.58 (0.38–0.72)*** DAPSA 0.74 (0.60–0.83)*** 0.71 (0.56–0.81)*** PD sum score 0.24 (−0.01–0.46)* 0.29 (0.05–0.50)* GLUS 0.30 (0.06–0.51)* 0.37 (0.13–0.56)** *p<0.05; **p<0.005; ***p<0.0001. r: correlation coefficient; CI: confidence interval; PD sum score: semi-quantitative score of joints, entheses, tendons and perisynovial tissue with power Doppler signals; GLUS: global ultrasound score. Conclusions This cross-sectional study shows that the ASDAS might also be a valuable tool to measure disease activity and to define clinical remission in PsA. References Helliwell PS. Assessment of disease activity in psoriatic arthritis. Clin Exp Rheumatol 2015;33:S44–7. Lukas C, Landewe R, Sieper J, Dougados M, Davis J, Braun J, et al. Development of an ASAS-endorsed disease activity score (ASDAS) in patients with ankylosing spondylitis. Ann Rheum Dis 2009;68:18–24. 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