L. Terslev

Clinical images: Ultrasonographic signs of gout in symmetric polyarthritis

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OP0155 Ultrasound as an outcome measurement tool for optimisedmonitoring of gout. validation of the omeract ultrasound definitions of gout elementary lesions

Objectives To evaluate ultrasound (US) as an outcome measurement instrument for monitoring gout patients during urate lowering therapy using the OMERACT US Working Group’s 2015 definitions of US elementary lesions in gout. Methods US examination (28 joints, 26 tendons) were performed in patients with microscopically verified gout who either initiated or increased urate lowering therapy. Joints and tendons were evaluated for the four OMERACT elementary lesions of gout (Double contour, Tophus, Aggregates and Erosions). Furthermore, subcutaneous (SC) oedema was registered and synovitis was graded by grey scale (GS) and colour Doppler (CD) (both graded 0–3). A sum score was calculated for each component for each patient (table 1). Patient Reported Outcomes (PROs) regarding pain (visual analogue scale), numbers of attacks within the last 3 months and physical function (Health Assessment Questionnaire) were obtained, as were C-reactive protein (CRP), p-urate and clinical joint examination. All examinations were repeated after 3 (n=29) and 6 months (n=15, follow-up still ongoing) and changes in scores were evaluated using Wilcoxon-Pratt signed-rank test. Results 29 patients (28 males, 1 female), mean age of 68 (39 – 89) years were included. US showed a numerical, but statistically non-significant (p=0.13), decline in DC count from baseline to 3 months’ follow up, while at 6 months a statistically significant decline was observed (p=0.033). The tophus count decreased non-significantly at both 3 and 6 months’ follow up, whereas the aggregate and erosion counts by large were unchanged. GS synovitis showed a statistically non-significant decrease at follow ups, whereas CD synovitis and SC oedema counts declined significantly at 3 months’ follow up (p=0.033u2009and 0.044, respectively). P-urate levels decreased statistically significant from baseline to both 3 and 6 months’ follow-up (both p-values<0.001), as did clinical markers such as CRP, joint evaluation, pain and attack frequency.Abstract OP0155 – Table 1 Course of US, biochemical and clinical variables during urate lowering therapy Conclusions Of the four OMERACT US elementary gout lesions only DC count showed a statistically significant decrease as a response to 6 months of urate lowering therapy. The number of tophi had decreased at both 3 and 6 months’ follow up, but not statistically significant. Aggregates and erosions count did not markedly respond to the 6u2009month treatment. The study indicates that US assessing the OMERACT elementary lesions, particularly DC, is a feasible tool for monitoring gout lesions. However, a follow-up of at least 6 months may be needed to detect change of crystal deposits, as reflected by DC, and presumably an even longer follow-up period is needed to evaluate more massive deposits as tophi. Disclosure of Interest None declared

FRI0229 The validity of the omeract ultrasound definitions of gout elementary lesions in the diagnosis of gout

Objectives The aim was to evaluate ultrasound (US) as a diagnostic tool for gout using the OMERACT US Working Group’s 2015 US definitions for elementary lesions in gout using a) positive urate crystal microscopy or b) clinical diagnosis of gout blinded to the US assessment as gold standard for determining the sensitivity and specificity of each elementary lesion. Methods US examination (28 joints, 26 tendons) were performed in patients with clinically suspected gout. Joints were evaluated for the four OMERACT elementary lesions of gout (Double contour (DC), Tophus, Aggregates and Erosions) and tendons for aggregates and tophus. The lesions were registered as either present or absent for each patient. The US assessment was compared to 2 different gold standard references: 1) presence/absence of monosodium-urate (MSU) crystals by joint fluid microscopy and 2) the final clinical diagnosis based on the clinical assessment by a rheumatologist, blinded to US findings but not microscopy findings (table 1). Results 51 patients (44 males, 7 female), mean age of 62(30 – 89) years were included. 34 of these had a positive microscopy for MSU crystals whereas 15 patients had a negative microscopy and in 2 patients joint aspiration was not possible. Of the patients without positive microscopy 3 were clinically diagnosed as having gout by a US blinded assessor whereas 14 were diagnosed with other diseases. DC, tophus and aggregates were found to be statistically significantly more frequent in both patients with positive MSU microscopy and in patients with clinically diagnosed gout (p-values range from 0.003 to <0.0001), compared to patients with negative MSU microscopy and other clinical diagnoses, respectively. All four elementary lesions were found to have high sensitivity (ranges from 0.74–0.88) for gout, both when MSU microscopy and when clinical diagnosis was used as gold standard reference. DC and aggregates had the highest sensitivities (0.85–0.88). Low specificity (0.33–0.64) was found for both aggregates and erosions, both when microscopy and clinical diagnosis was considered the gold standard. In contrast, DC and tophus showed high specificities for patients with microscopically proven gout (0.73 and 0.87, respectively) and particularly patients with clinically diagnosed gout (both 0.93). DC and tophi were also found to have high positive predictive values (PPV) for gout for patients with microscopically proven gout (0.88 and 0.93, respectively) and especially for patients with clinically diagnosed gout (both 0.97). In contrast negative predictive values (NPV) were relatively low for all lesions (ranges from 0.36–0.72).Abstract FRI0229 – Table 1 US findings in patients with microscopically proven or clinically defined gout. Conclusions The OMERACT US definitions of gout elementary lesions seem to be a valid tool for diagnosis of gout in clinical practice. Particularly, DC and tophi seem to have a high specificity and high PPV for the disease. Disclosure of Interest None declared

SAT0659 Is synovial hypertrophy without doppler activity in rheumatoid arthritis joints sensitive to change? – results of a longitudinal ultrasound study

Background Ultrasound (US) is used to assess diseases activity in rheumatoid arthritis (RA). Grey scale (GS) US shows the synovial hypertrophy (SH) and Doppler the amount of hyperemia which is believed to reflect disease activity. Some joints with SH may have no Doppler activity despite the use of high-end US equipment and these joints are generally believed to be inactive without potential to change. Objectives The aim was to investigate if joints with SH but no Doppler activity is sensitive to change during treatment with biological DMARD (bDMARD) in RA patients. Methods RA patients initiating or changing bDMARD treatment were included. US examination was performed at baseline, 3 and 6 months using Siemens Antares US equipment with Doppler settings for slow flow. 36 joints were evaluated at each visit. SH and Doppler activity was graded from 0–3 according to the US atlas by Hammer et al.(1 The GS score for SH in joints without Doppler activity was registered for the individual joints using GS SH ≥1 as threshold. The changes were compared to changes in SH in joints with Doppler activity. Results 151 patients (82.8% women, 80.1% seropositive for anti-CCP) were included, with a mean (SD) age 51.4 (13.2) years, disease duration 9.9 (7.9) years. At baseline, 50.7% used prednisolone (mean (SD) 5u2009mg (4.68)). The patients had a mean (SD) baseline DAS28 of 4.5 (1.5). At baseline 23% of the joints had SH without Doppler activity and 23% of the joints had SH with Doppler activity. Doppler-negative joints had overall lower grades of SH (mean 1.2) than Doppler-positive joints (mean 2.2) at baseline using GS SH >1 as cut-off. The improvement in SH was similar in Doppler-positive and Doppler-negative joints but when adjusting for the baseline score of SH, Doppler-negative joints had a higher tendency towards decrease than Doppler-positive joints for all grades (3 months: p<0.0001; 6 months=0.0006). A weak correlation was found to changes in DAS 28(crp) (Doppler-negative joints:0.27 (p=0.001) and 0.18 (p=0.03) at 3 and 6 months respectively – Doppler-positive joints: 0.25 (p=0.004) and 0.33 (p=0.0002) at 3 and 6 months respectively). Conclusions SH in joints without Doppler activity improves during bDMARD, i.e is sensitive to change. Thus, SH without Doppler activity is not a sign of inactive disease. These findings document that both Doppler and SH should be evaluated when assessing disease activity by US. Reference [1] Hammer HB, Bolton-King P, Bakkeheim V, et al. Examination of intra and interrater reliability with a new ultrasonographic reference atlas for scoring of synovitis in patients with rheumatoid arthritis. Ann Rheum Dis2011;70:1995–8. Disclosure of Interest None declared

SAT0631 Inter-observer and intra-observer reliability of the omeract ultrasonographic (US) criteria for the diagnosis of calcium pyrophosphate deposition disease (CPPD) at the metacarpal-phalangeal (MCP), wrist, acromion-clavicular (AC) and hip joints

Background The OMERACT US subtask force “US in CPPD” recently created the definitions for US identification of crystal deposits in joints and tested the reliability at the knee [1]. Objectives To assess the inter/intra-observer reliability of US on detecting CPPD at triangular fibrocartilage complex (TFCC) of the wrists, fibrocartilage of the AC joint, hip labrum (HL), hyaline cartilage (HC) of the metacarpal (MC) and femoral head. Methods The OMERACT criteria for CPPD were used for the exercise [1] using a 2 steps approach. First, the panel of experts gave a dichotomous score (presence/absence of CPPD) of 120 images of the sites included, using a web platform. The images were evaluated twice to assess the inter/intra-observer reliability. Then, the experts met in Siena for a patient based exercise. Bilateral evaluation of TFCC, AC, HL /HC of the hip and HC of the II-III MCP of 8 patients was carried out twice in a day, using a dichotomous score for CPPD. 8 US machines (3 GE, 1 Samsung and 4 Esaote) equipped with high resolution linear probes were used. Results Reliability values of static exercise were high for all sites, demonstrating that definitions were clear. The results of the second step are presented in table 1. On live scanning, the TFCC resulted the most reliable site for CPPD assessment, followed by AC. Other sites demonstrated lower kappa values and thus are not reliable for CPPD assessment. Conclusions TFCC of the wrist is the most reliable site for CPPD. By adding these results to the previous [2], we confirm that the OMERACT definitions for CPPD can be applied reliably at the knee (meniscus and HC), TFCC and AC, usually the most involved sites in CPPD. The next step of the OMERACT subtask force will be to test these findings in a longitudinal observational study. References Filippou G, Scirè CA, Damjanov N et al. Definition and reliability assessment of elementary US findings in CPPD. Results of an international multi-observer study by the OMERACT sub-task force “US in CPPD”. J Rheumatol, in press. Disclosure of Interest None declared

OP0288 Reliability of a eular-omeract semiquantitative scoring system for the assessment of cartilage in rheumatoid arthritis

Background Joint destruction in rheumatoid arthritis (RA) is comprised of hyaline cartilage and bone damage, with the former more clearly associated with irreversible physical disability than bony damage. Objectives To test the reliability of a semiquantitative scoring system for the assessment of cartilage by musculoskeletal ultrasound (US) in a web-based exercise as well as a patient-based reliability study of patients with RA. Methods Static images of metacarpophalangeal (MCP) joints 2–5 in RA patients and healthy controls were acquired and a dataset of 123 anonymized images including 25 duplicate images was circulated among an international EULAR-OMERACT taskforce of 25 rheumatologist experts in US who independently scored the images using a semiquantitative scoring system. Subsequently 12 taskforce members participated in a patient-based reliability study. During this meeting MCP joints 2–5 of 6 patients with RA were assessed twice on the same day by all experts using US machines (GE) equipped with high-frequency transducers (18–22MHz) with presets calibrated for the appropriate assessment of cartilage. Participants assessed metacarpal cartilage both in the standardized longitudinal midline scan as well as by freehand technique utilizing multiple planes and scored by the semiquantitative scoring system. Intraobserver reliability was assessed by Cohens kappa and interobserver reliability by Fleiss kappa. Results The three-grade semiquantitative (Grade 0, normal cartilage; Grade 1, minimal change; Grade 2, severe change) scoring system demonstrated excellent (kappa: 0.87) to good (kappa: 0.73) intraobserver reliability in the web-based exercise and the patient-based reliability study respectively. Interobserver reliability was good in the web-based exercise (kappa: 0.64) and moderate (kappa: 0.49) in the patient-based reliability study. The dynamic technique performed slightly better than the longitudinal midline scan alone. Conclusions A semiquantitative scoring system demonstrated good intra- and moderate to good inter-observer reliability in a web-based exercise and patient-based reliability study. Our study demonstrates that US is a reliable tool for evaluating cartilage and supports the use of a new semiquantitative US scoring system for evaluating cartilage change in RA. Acknowledgements The patient-based reliability study was supported by a research grant from UCB. Disclosure of Interest None declared

OP0122 Inter-Reader and Intra-Reader Reliability of The New Omeract Ultrasonographic Criteria for The Diagnosis of CPPD

Background Ultrasonography (US) has been implemented recently as a possible diagnostic method for CPPD [1]. However, data on the reliability of US in CPPD diagnosis are lacking Objectives To assess the inter-reader and intra-reader reliability of US on detecting CPP deposition in fibrocartilage (FC), hyaline cartilage (HC), tendons (T) and synovial fluid (SF) Methods The OMERACT “US in CPPD” group defined firstly the US CPPD identification criteria according to methods described in an another abstract submitted in this congress. Subsequently, a two steps procedure for the assessment of the reliability has been followed. Firstly, the panel gave a dichotomous score on the presence absence of CPPD in 150 photos of FC, HC, T and SF equally distributed, on a web based platform. The assessment has been carried out twice in order to calculate both inter and intra-reader reliability. In the second step, the experts met for a real life-patient based assessment of CPPD in a workshop organised in Siena-Italy. In that occasion, FC/HC/T/SF of the right knee and FC and SF of the right wrist of 8 patients were assessed twice in a day by all experts giving again a dichotomous score for CPPD. 8 US scanners (ESAOTE mylab seven) equipped with the same probe and the same preset (made ad hoc before the meeting), have been used for the workshop. Results Reliability values of the web based exercise and of the workshop are presented in table 1. Tendons and synovial fluid analysis did not reach sufficient strength of agreement neither on the web based nor in the patient based exercise regarding the inter-reader kappa and independently of the site. However, in the static exercise, both tendons and SF reached a good intra-reader reliability meaning that scanning technique of these structures is very important for CPPD identification. On the other hand, menisci (but not triangular FC of the wrist) and HC reached good kappa values for inter-reader and intra-reader agreement both on static and web-based exercise Conclusions Knee cartilage and fibrocartilage structures resulted to be reliable enough for identification of CPPD. On the other hand, CPPD identification in tendons and synovial fluid is challenging and the actual OMERACT criteria for these sites do not ensure a safe classification of patients. OMERACT US criteria for CPPD identification in knee menisci and HC allow a reliable classification of patients and should be used when CPPD is suspected. References Zhang W, Doherty M, Bardin T, et al. European League Against Rheumatism recommendations for calcium pyrophosphate deposition. Part I: terminology and diagnosis. Ann Rheum Dis 2011;70:563–70 Disclosure of Interest None declared

FRI0517 The Omeract Ultrasonographic Criteria for Elementary Lesions in Calcium Pyrophosphate Deposition Disease: Results of A Delphi Process by Ultrasound Working Group

Background In the last years, the role of Ultrasound (US) for the diagnosis of calcium pyrophosphate deposition disease (CPPD) has been extensively growing. However, some issues have still to be resolved, being one of the most important the heterogeneity of the criteria used for the identification of calcium pyrophosphate crystals (CPP) deposits. Objectives The aim of this study was to define the US elementary lesions in CPPD Methods The panel of experts was compound by 18 members of the Omeract US group, especially interested in microcrystalline arthritides. The first step was a systematic literature review aimed to select the studies regarding US and CPPD in order to collect all the definitions about US elementary findings in CPPD. The definitions retrieved by the literature were used for drawing up a first group of propositions. The experts evaluated these definitions, adding any further preposition according to their experience that could improve the initial set. According to the systematic review, the propositions about US elementary lesions were divided by anatomical structure: fibrocartilage, hyaline cartilage, tendons and synovial fluid. For each structure were defined: shape, echogenicity, localization and behaviour at dynamic scanning. In the next rounds, the experts voted their level of agreement for each proposition according to the Likert scale (1 strongly disagree 5:strongly agree) with the possibility to add comments. After each round, a facilitator modified the prepositions according to the comments received. The consensus for each preposition was considered achieved if the agreement was equal or more than 75% Results Three Delphi rounds were necessary in order to reach agreement. After the first round, 20 of the 93 definitions retrieved by the literature reached the consensus. During the second one, 23 propositions achieved the agreement while, after the last Delphi round, the number of propositions increased to 27. All the members responded to all the phases of the survey. Final definitions for US identification of CPPD are illustrated in Table 1 Conclusions To our knowledge this is the first set of definitions for US identification of CPPD created according to a consensus procedure between experts. These definitions should help sonographers to classify correctly patients with suspected CPPD thus giving the possibility to organise multicentre studies. However, the reliability and the diagnostic accuracy of this set has to be assessed before they become integral part of the daily clinical practice Disclosure of Interest None declared

A structured and extensive training program on vascular ultrasound, results in an excellent agreement between ultrasound and temporal artery biopsy in the diagnosis of giant cell arteritis

Are Ankylosing Spondylitis, Psoriatic Arthritis and Undifferentiated Spondylarthritis Associated with an Increased Risk of Cardiovascular Disease?For a searchable version of these abstracts, please visit www.acrabstracts.org. Please Note: It may take several minutes for this file to download.Background/Purpose: Person-centred care (PCC) is a holistic approach with respectful and individualized care allowing negotiation of care where persons with health problems are empowered to be involved in health decisions. Patients’ illness narratives constitute a starting point for building a collaboration with health care professionals and to empower them to play an active role in their health care. Little is known of the impact of PCC vs. regular care on patients’ skills as health care consumers. The aim was to study the impact on effective consumers’ skills over 6 and 12 months as measured by the Effective Consumer Scale (EC17) in patients undergoing biological therapy and randomly assigned to either a nurse-led rheumatology clinic (NLC) based on PCC or to a rheumatologist-led clinic (RLC) based on regular care.Methods: A 12 month RCT in 107 patients with chronic inflammatory arthritis1. Inclusion criteria were ongoing biological therapy and a DAS28 ≤3.2. All patients met a rheumatologist at inclusion and after 12 months, while the 6 month follow-up was randomized to either at an NLC (PCC) or at an RLC (regular care). Outcome measure was the EC17, developed and endorsed by the OMERACT, including five subscales; 1. Use of health information, 2. Clarifying personal priorities, 3. Communicating with others, 4. Negotiating roles and 5. Deciding and taking action. EC17 total score ranges from 0-100, worse to best. Differences between and within NLC and RLC were analyzed with Friedmans’ test or Mann Whitney U-test.Results: After 12 months 97 patients completed the RCT (NLC n=47, RLC n=50), mean (SD) age 55.4 (12.7) years, disease duration 16.7 (11.5) years, DAS28 2.1 (0.7), HAQ 0.54 (0.38), global health 20.4 (17.1), pain 21.1 (18.0) and 56% were women. There were no statistically significant differences within or between the two intervention groups at baseline nor in EC17 total score mean (SD) at baseline (NLC 83.5 (9.4) vs. RLC 83.2 (10.8), 6 months (NLC 85.4 (10.4) vs. RLC 82.9 (10.9) and 12 months (NLC 85.3 (11.1) vs. RLC 82.3 (10.9)). However, in NLC there was a statistically significant improvement in EC17 subscale “1. Use of health information” at both 6 and 12 months (p=0.041 and p=0.004 respectively).Conclusion: Replacing just one of three visits over 12 months to an NLC based on PCC instead of an RLC based on regular care resulted in more effective consumers concerning the use of health information. Larger studies over longer time frames focusing on PCC are needed to better understand its full impact on effective consumer skills measured by EC17.References:1. Larsson I, et al. Randomized controlled trial of a nurse-led rheumatology clinic for monitoring biological therapy. J Adv Nurs 2014;70:164-75.Background/Purpose: Chronic widespread pain (CWP), one of the hallmarks of fibromyalgia, is not uncommon in adolescents and it has previously been shown that adolescents with pain often become young adults with pain. CWP often co-varies with anxiety, depression, and stress symptoms in adults, but the knowledge regarding this is small in youth and young adults.The aim was to study the associations between CWP, anxiety, depression and stress in adolescents attending first year of high school.Methods: A computerized questionnaire to 296 adolescents attending Swedish high school, with validated questions regarding presence and distribution of pain (Epipain mannequin), stress symptoms (ELO question), anxiety and depression (Hospital Anxiety and Depression Scale – HADS), and health related quality of life (HRQL as measured by EQ5D). Pain was considered chronic when persistent for more than three months, and the subgroup CWP was defined according to the 1990 ACR criteria for fibromyalgia. Statistical analyses in SPSS v21 with comparison of means by Student’s t-test and proportions by chi2-test or Fischer’s exact test.Results: 257 (87%) out of 296 eligible students, mean (SD) age 16.1 (0.7) and 65.8% girls, responded to the questionnaire. Prevalence of chronic pain was 20.8% and that of the subgroup CWP was 4.7%, without any gender differences (boys 18.2% vs girls 22.2%; p=0.224, and 3.4% vs 5.4%; p=0.692). High level (4 or 5 on a 5 point scale) of stress symptoms were less common in boys (16.0% vs 28.2%; p=0.015), as was possible or probable anxiety (17.1% vs 44.4%; p<0.001), but not depression (10.3% vs 12.5%; p=0.764). Students with high level of stress reported CWP five times more often than those with less stress (30.4% vs 5.8%; p=0.001). Students with probable anxiety reported CWP ten times more often than students with no anxiety (17.6% vs 1.8%; p=0.001), and CWP was also more common, but not statistically significant, in students with probable depression (20.0% vs 3.1%; p=0.163). Those reporting CWP had significantly lower HRQL (0.58 vs 0.87; p=0.038) than students with no chronic pain.Conclusion: The high prevalence of chronic pain and the strong associations between CWP and reports of stress and anxiety in adolescents highlights that a multifactorial background to chronic pain must be considered early in life. An apparent lower score in EQ5D also indicates that the presence of CWP has an marked impact on HRQL also in adolescents.Background/Purpose: The treatment target for axial spondyloarthritis (SpA) is to maximize health-related quality of life (HRQoL) by controlling disease activity and improving functioning. The treatment cornerstones are a combination of patient education, pharmacological and non-pharmacological treatment. Health professionals are familiar with providing patient education but the knowledge is scarce concerning how this education is experienced by the patients.The aim was to describe patients’ experiences of education in SpA management.Methods: The study had a descriptive design with a qualitative conventional content analysis approach performed in seven steps in accordance with Graneheim & Lundman (1). The analysis aimed to describe and preserve contextual meanings. After coding and subgrouping meaningful parts of the text were merged into categories. Eleven interviews were conducted between 2014-2015 in patients with SpA based on a strategic sampling in order to achieve variation with regard to sex (7 men, 4 women), age (38-66 years), subdiagnoses (5 patients with AS, 6 with USpA), quality of life (EQ5D 0.29-1.0), disease activity (BASDAI 1-6), physical function (BASFI 0-5), and global health (BASG 0-7) .Results: Three categories representing patients’ experiences of patient education in disease management emerged; guiding education, reliable education and available education. Guiding education comprised SpA management including disease knowledge such as symptoms, prognosis, treatment, self-management, climate impact, heredity, and assisting devices. Reliable education meant how and by whom the education was communicated and was considered reliable if it was based on science and communicated by specialists, for example by physician, nurse, PT, dietician and senior patients with experience of rheumatic diseases. The patients experienced difficulties in assessing the large flow of education coming from various sources. Individualized education also increased the reliability. Available education meant that the education can and should be presented in varied formats, and that the amount of information could be chosen. The education could be given orally (through meetings, videos, lectures), in writing (by pamphlets, e-mails, journals, webpages) or obtained through own personal experiences. There were requests to utilize newer media like skype, video and chat forums. Furthermore, individual contacts with healthcare professionals when needed were of importance.Conclusion: This study highlights the importance of obtaining a guiding, reliable and available patient education for management of SpA. Health care professionals need to consider the importance of presenting varied formats of education based on patients’ experiences and expectations.References:1.Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse education today 2004;24(2):105-12.PMN Reactivity Contribute to Acute Onset Joint Inflammation By Increasing CXCL8 Production in Joints of RA Patients with Anti-Collagen II AntibodiesBig Data International Primary Sjogren Syndrome Registry : Baseline Characterization and Diagnostic Approach in 6047 Patients Fulfilling the 2002 AE CriteriaThe Link Between DAS28 and the Short-Term Risk of Acute Coronary Syndrome in RA, and Its Driving FactorsHypomethylation in Enhancer and Promoter Regions of Interferon Regulated Genes in Multiple Tissues Is Associated with Primary Sjogrens SyndromeReceptor Activator of Nuclear Factor Kappa-B Ligand (RANKL) and Sclerostin Are Related to Joint Destruction in Early Rheumatoid Arthritis Unrelated to Polymorphisms of the Genes

AB1089 Introducing Vascular Ultrasound in the Diagnosis of Giant Cell Arteritis in Denmark

Background There is an increasing use of vascular ultrasound (US) as a diagnostic tool in Giant Cell Arteritis (GCA) internationally. Therefore, it is of great importance to develop and standardise examination technique, machine settings and offer proper training of ultrasonograhers to ensure a high level of expertise in order to obtain reliable results Objectives The aim of this study is to evaluate a specific vascular US training program in GCA diagnostic. Methods Patients suspected for GCA were US evaluated by five rheumatologists with long-standing experience in musculoskeletal US who were trained by the following program: Participation at the International Workshop on ultrasound in Large Vessel Vasculitis & Polymyalgia Rheumatica in Kristiansand, Norway (5 hours theoretical and 10 hours supervised hands-on education). Later, further training and standardisation was obtained at a two days workshop (Esbjerg, Denmark) including training with both healthy persons and GCA patients (totally 6 hours of supervised hands-on trainings and 1 hour of image evaluation). High-end equipment (Hitachi Preirus & GE logic-9E), with comparable settings and standardized examinations methods was used. As part of an ongoing study the following arteries were evaluated bilaterally: temporal artery (common, pariental and frontal branch)(AT), the facial artery (AF), the common carotid artery (AC)and the axillary artery (AA). Both still images in two planes and films were recorded. Images were subsequently evaluated first by the performing ultrasonographer and after by a blinded external expert (gold standard). Detailed feedback on the US technique was given to the performing ultrasonographer by the external expert. US was considered positive when a homogeneous hypoechoic thickness >1.5 mm in AC and >1mm in AA, in transverse and longitudinal view was observed. For the AT and AF, the halo sign (hypoechoic arterial wall swelling in transverse and longitudinal view) and/or positive compression-sign (impaired compression) was considered a sign of vasculitis Results Twenty patients suspected for GCA were enrolled in a period of 8 months in 3 Danish centres (Esbjerg, Glostrup, Silkeborg) In all ten patients with positive Temporalis Artery Biopsy (TAB) was found US vasculitis in AT according to both external expert and performing ultrasonographer. Arteritis in AA was found in 3/10 according to external expert and in 4/10 patients according to performing ultrasonographer In the rest 10 patients with negative TAB were no sign of US vasculitis in AT and AF (external expert) and according to performing ultrasonographer there was US AT vasculitis in 1/10. Arteritis in the extracranial arteries was found in 2 patients (bilateral in AA) according to both expert and ultrasonographer. Totally, 240 vessels were scanned and vasculitis changes were observed in 58 vessels (expert) and in 55 vessels (performing ultrasonographer). The inter-observer agreement between the performing ultrasonographer and the blinded expert was excellent in all 3 centre (table) Cohens kappa-coefficient Esbjerg k=0,89,Glostrup k=0,91 & Silkeborg k=0,82. Conclusions The above mentioned educational program showed excellent results in diagnostic of GCA and excellent interobserver agreement. It could be considered as a teaching model to vascular ultrasound in the diagnosis of GCA Disclosure of Interest None declared