Marika Tardella

Development of a preliminary US power Doppler composite score for monitoring treatment in PsA

OBJECTIVE To develop a preliminary power Doppler (PD) US composite score for global assessment of PsA patients. METHODS Sixteen PsA patients receiving anti-TNF-α therapy were enrolled. All patients were involved in multiple psoriatic targets, including joints, tendon, enthesis, skin and nail. The target with the highest PD signal, one for each target area, was selected to be scanned at baseline and at follow-up visit 8 weeks after. For each target, PD was graded according to semi-quantitative scoring systems. Inter- and intra-observer reliability and feasibility was also investigated. The new PD composite score for PsA was called Five Targets PD for Psoriatic Disease (5TPD). RESULTS Sixty targets (16 joints, 9 tendons, 11 enthesis, 16 psoriatic plaques and 8 psoriatic onychopathies) were assessed. A significant improvement of the clinical scores was found at follow-up with respect to the baseline: HAQ modified for SpA (HAQ-S) (P = 0.0001); Psoriasis Area and Severity Index (P = 0.0001) and Nail Psoriasis Severity Index (P = 0.35). The 5TPD showed a significant change between baseline and follow-up (P = 0.0001). There was no significant correlation between HAQ-S and 5TPD findings. The inter- and intra-observer κ-values varied from good to excellent at baseline and follow-up. The time spent on baseline US examinations was mean (s.d.) 10.5 (2.0) min and no more than 7 min for follow-up assessment. CONCLUSION The present study provides a new working hypothesis that the sonographic core set may be useful to construct a PDUS composite score for the assessment of PsA. The 5TPD formula provides a feasible and reliable approach for multi-target monitoring of psoriatic disease.

Interobserver reliability of ultrasonography in the assessment of cartilage damage in rheumatoid arthritis

Objectives To evaluate the interobserver reliability of ultrasonography (US) in the assessment of cartilage damage at metacarpophalangeal (MCP) joint level in patients with rheumatoid arthritis (RA). Methods US examinations were performed on 80 MCP joints of 20 patients with RA using a MyLab70 XVG (Esaote Biomedica, Genoa, Italy), equipped with a broadband linear probe (6–18 MHz). For each patient, second and third MCP joints of both hands were examined independently on the same day by two rheumatologists (an experienced musculoskeletal sonographer and an investigator with limited US training). A multiplanar scanning technique on dorsal, lateral and volar aspects of the MCP joints was adopted. All US pathological findings were documented on at least two perpendicular scanning planes. Each joint was assessed by quadrant for the presence or absence of cartilage damage. Cartilage damage was also scored per quadrant on a five-grade semiquantitative scoring system on which investigators reached a consensus prior to the study. Results Exact agreement between investigators was found in 173 out of 200 quadrants (86.5%) with regard to presence or absence of cartilage damage. Percentages of exact agreement for cartilage damage semiquantitative assessment at dorsal, lateral and volar quadrants were 72.5%, 52.5% and 85%, respectively, while unweighted κ values were 0.561, 0.366 and 0.766, respectively. Conclusions The present study demonstrated moderate to good interobserver reproducibility of a semiquantitative scoring system based on qualitative morphological changes for cartilage damage at MCP joint level in patients with RA.

Extent and distribution of CPP deposits in patients affected by calcium pyrophosphate dihydrate deposition disease: an ultrasonographic study

Objective To assess the extent of calcium pyrophosphate dihydrate (CPP) crystal deposition and the distribution of affected sites, using ultrasonography (US), in patients affected by CPP deposition disease (CPPD). Patients and methods 42 consecutive patients affected by definite CPPD according to the McCarty criteria were enrolled in the study. All patients underwent an US examination of metacarpophalangeal joints of II, III, IV and V fingers of both hands, wrists and knees, Achilles’ tendons and plantar fascia looking for CPP deposits. A dichotomous score for presence/absence of CPP and a semiquantitative score for extent of deposits (0–3: 0, absent; 1, 1–2 spots; 2, more than two spots covering <50% of the structure; 3, deposits covering >50% of the structure) were assigned to each site examined. A site distribution score (total number of affected sites) was then calculated as well as an extent score equal to the sum of the extent scores of all sites. Results The mean involvement in our patients was 4.7 sites (SD±1.7, range 2–8 sites). The knee was the most affected, site (41 of 42) followed by the wrist (at least one in 37 patients) the Achilles’ tendons (23 patients), plantar fascia (11 patients) and metacarpophalangeal joints (four patients). The highest mean values of the extent score were in the menisci, followed by the hyaline cartilage of the femoral condyles and the entheses. Conclusions The deposition of CPP crystals involves at least two sites with a mean of four sites involved in most patients affected by CPPD and is therefore an oligoarticular or polyarticular disease.

Ultrasound in the assessment of pulmonary fibrosis in connective tissue disorders: correlation with high-resolution computed tomography.

Objective. To investigate the correlation between ultrasound (US) B-lines and high-resolution computed tomography (HRCT) findings in the assessment of pulmonary fibrosis (PF) in patients with connective tissue disorders (CTD). Methods. Thirty-four patients with a diagnosis of CTD were included. Each patient underwent clinical examination, pulmonary function test (PFT), chest HRCT, and lung US by an experienced radiologist or rheumatologist. A second rheumatologist carried out US examinations to assess interobserver agreement. In each patient, US B-line lung assessment including 50 intercostal spaces (IS) was performed. For the anterior and lateral chest, the IS were the second to the fifth along the parasternal, mid-clavicular, anterior axillary, and medial axillary lines (the left fifth IS of the anterior and lateral chest was not performed because of the presence of the heart, which limits lung visualization). For the posterior chest, the IS assessed were the seventh to the eighth along the posterior-axillary and subscapular lines. The second to eighth IS were assessed in the paravertebral line. In each IS, the number of US B-lines under the transducer was recorded, summed, and graded according to the following semiquantitative scoring: grade 0 = normal (< 10 B-lines); grade 1 = mild (11 to 20 B-lines); grade 2 = moderate (21 to 50 B-lines); and grade 3 = marked (> 50 B-lines). Results. A total of 1700 IS in 34 patients were assessed. A significant linear correlation was found between the US score and the HRCT score (p < 0.001; correlation coefficient ρ = 0.875). A positive correlation was found between US B-line assessments and values of DLCO (p = 0.014). Both κ values and overall percentages of interobserver agreement showed excellent agreement. Conclusion. Our study demonstrates that US B-line assessment may be a useful and reliable additional imaging method in the evaluation of PF in patients with CTD.

Utility of a simplified ultrasound assessment to assess interstitial pulmonary fibrosis in connective tissue disorders - preliminary results

IntroductionInterstitial pulmonary fibrosis (IPF) is a frequent manifestation in patients with connective tissue disorders (CTD). Recently the ultrasound (US) criterion validity for its assessment has been proposed; however, the US scoring systems adopted include the study of several lung intercostal spaces (LIS), which could be time-consuming in daily clinical practice. The aim of this study was to investigate the utility of a simplified US B-lines scoring system compared with both the US comprehensive assessment and the high-resolution computed tomography (HRCT) findings of IPF in CTD patients.MethodsThirty-six patients with a diagnosis of CTD were enrolled. Each patient underwent chest HRCT and lung US by an experienced radiologist and rheumatologist, respectively. Both comprehensive and simplified US B-lines assessments were scanned. The comprehensive US assessment was performed at 50 LIS level, whereas the simplified US assessment included bilaterally 14 LIS; for the anterior chest: the second LIS along the para-sternal lines, the fourth LIS along the mid-clavear, anterior axillary and mid-axillary lines; for the posterior chest: the eighth LIS along the paravertebral, sub-scapular and posterior axillary lines.For criterion validity, HRCT was considered the gold standard. Feasibility, inter and intra-observer reliability was also investigated.ResultsA highly significant correlation between comprehensive and simplified US assessment was found (P = 0.0001). A significant correlation was also found between the simplified US assessment and HRCT findings (P = 0.0006). Kappa values for the inter-observer simplified US assessment were in a range from 0.769 to 0.885, whereas the concordance correlation coefficient values for the intra-observer were from 0.856 to 0.955. There was a relevant difference in time spent on comprehensive (mean 23.3 ± SD 4.5 minutes) with respect to the simplified US assessment (mean 8.6 ± SD 1.4) (P < 0.00001).ConclusionsOur results provide a new working hypothesis in favor of the utility of a simplified US B-lines assessment as an adjunct method to assess IPF in patients with CTD.

Interreader Reliability in Assessment of Nailfold Capillary Abnormalities by Beginners: Pilot Study of an Intensive Videocapillaroscopy Training Program

Objective. To test the learning curve of rheumatologists with different experience in videocapillaroscopy (VCP) attending an intensive training program focused on interpretation of the main capillary nailfold abnormalities, the scleroderma (systemic sclerosis, SSc) pattern, and the normal pattern, and to determine their interreader agreement with an experienced investigator. Methods. Five investigators (1 senior, 1 junior, and 3 beginners) participated in the exercise. The study was composed of 2 steps. First, an independent investigator selected representative VCP images of normal patterns and capillary abnormalities. The second step included the training program, which ran 4 hours per day for 7 days. The senior rheumatologist taught investigators to recognize and interpret the normal pattern, the capillary abnormalities, and the different types of SSc pattern. These abnormalities were considered: homogeneously enlarged capillaries, giant capillaries, irregularly enlarged capillaries, microhemorrhages, neoangiogenesis, avascular areas, and capillary density. Results. A total of 300 VCP images were read from all the investigators. Both κ values and overall agreement percentages of qualitative and quantitative assessments showed progressive improvement from poor to excellent from the beginning to the end of the exercise. The sensitivity and specificity of the participants in the assessment of SSc pattern at the last lecture session were high. Conclusion. Our pilot study suggests that after an intensive 1-week training program, novice investigators with little or no experience in VCP are able to interpret the main capillary abnormalities and SSc pattern and to achieve good interreader agreement rates.

Erosive cervical spine involvement in primary Sjögren’s syndrome

A 69-year-old woman, diagnosed with primary Sjögren’s syndrome that was characterized by the presence of sicca symptoms and anti-nuclear and anti-Ro antibodies and histologically confirmed with a minor salivary gland biopsy 11 years ago (Figure 1a), consulted our rheumatologic department for a recent onset of inflammatory neck pain. Physical examination revealed pronounced cervical stiffness, but no signs of synovitis in the peripheral joints. Magnetic resonance imaging of the cervical spine in sagittal T2-weighted scan showed the presence of synovitis of the atlantoaxial joint, with synovial pannus surrounding the odontoid process of the second cervical vertebra and compressing the cord (Figure 1b). Bone marrow edema and erosions were also detected in the odontoid process. Subsequent coronal (Figure 1c) and sagittal computed tomography scans (Figure 1d) confirmed the presence of well-defined multiple erosions at the base and apex of the odontoid process. Rheumatoid factor and anti-citrullinated protein antibodies were absent. X-rays of the hands, wrists, and knees revealed only mild signs of osteoarthritis. Marco Di Carlo1, Marina Carotti2, Francesco Sessa3, Daniele Roia1, Marika Tardella1, Fausto Salaffi1 Images in Rheumatology

SAT0413 Inter-reader reliability in the assessment of nailfold capillary abnormalities: A pilot study about an intensive videocapillaroscopy training programme

Background Nailfold videocapillaroscopy (VCP) has gained considerable interest by rheumatologists over the past years due its utility in both clinical practice and research, and has become an established method to assess the microcirculation “status” in patients with Raynaud’s phenomenon (RP) and systemic sclerosis (SSc). Although it has been demonstrated that technical skills in VCP can quickly be attained (1), the recognition and interpretation of both the “normal” VCP pattern and the pathological findings, typical of the “scleroderma pattern” (SP), require more time and a more careful standardization. Objectives To test the learning curve of four rheumatologists with little or no experience in VCP who attended an intensive training programme focused on the interpretation of the normal pattern, the main capillary abnormalities and SP, and to determine the inter-reader agreement compared with an experienced investigator. Methods Five investigators (1 senior, 1 junior with little experience in VCP and 4 beginners) participated in the exercise. The study consisted of two steps. In the first step, an independent investigator selected representative VCP images of normal patterns and SP patterns. The second step included the training programme that was run for 4 hours per day for seven days. The senior investigator provided the basic knowledge to recognize and interpret the normal pattern, the capillary abnormalities, such as giant capillaries, irregularly enlarged capillaries, micro-haemorrhages, and the different types of SP, according to Maricq (classification A) and Cutolo (classification B) (2,3). Results A total of 300 VCP images were assessed by all the investigators. Both k-values and overall agreement percentages of qualitative and quantitative assessments showed a progressive improvement, from poor to excellent, from the beginning to the end of the exercise. According to the classification A, the global κ values in the first session were 0.468 for the junior and 0.394, 0.529 and 0.514 for the 1st, 2nd and 3rd beginner respectively, whereas in the last session were 0.812 for the junior and 0.842, 0.844 and 0.794 for the 1st, 2nd and 3rd beginner respectively. For the classification B the global κ values in the first session were 0.349 for the junior and 0.391, 0.398 and 0.397 for the 1st, 2nd and 3rd beginner respectively whereas they were 0.786 for the junior and 0.812, 0.743 and 0.832 for 1st, 2nd and 3rd beginner, respectively, in the last session. Both sensitivity and specificity in the assessment of SP at the last session of reading were high (100% and 86% for the junior; 99% and 79% for the 1st beginner; 99% and 82% for the 2nd beginner; 98% and 79% for the 3rd beginner). Conclusions Our pilot study suggests that after a short intensive, one-week training programme, novice investigators in VCP are able to correctly assess the normal pattern and the SP achieving good inter-reader agreement rates. References De Angelis R, et al. Clin Exp Rheumatol 2009;27:651-3. Maricq HR. Arthritis Rheum 1981; 24:1159-65. Cutolo M, et al. J Rheumatol 2000;27: 155-60. Disclosure of Interest None Declared