O. De Lucia

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

SAT0304 Preclinical phases of psoriatic arthritis: a cross-sectional ultrasonographic study on psoriasis and psoriatic arthralgia patients

Background Identify the preclinical phase of arthritis could be clinically relevant. In this scenario, musculoskeletal ultrasonography (US) may play an important role, since it may detect subclinical disease. Psoriatic Arthritis (PsA) is a perfect disease to identify risk factors, since the risk pool group [i.e. patients with only cutaneous Psoriasis (Pso)] is known. Objectives To evaluate in Pso patients, with and without clinical arthralgia (CA), defined by the presence of joint pain without other clinical evidence of musculoskeletal inflammation: I) the prevalence of subclinical US inflammation in joints, enthesis, tendons and bursae; II) the prevalence of US structural damage; III) the relationship between US lesions and clinical data. Methods Cross-sectional prevalence study of US abnormalities in Pso patients with or without CA and healthy controls (HCs). Inclusion and exclusion criteria (e.g. osteoarthritis and fibromyalgia) are pre-defined. Forty-four joints (MCP, PIP and DIP joints, wrists, knees, MTP joints) and 12 enthesis (achilles, quadriceps, proximal and distal patellar, plantar aponeurosis and common extensor tendon enthesis) were scanned in each patient. US scans were performed using a ESAOTE MyLabClassC equipped with a high frequency linear probe. Active synovitis was defined by the presence of a grade ≥2 for grey scale (GS) and ≥1 for PD, while active enthesitis if there was hypoecogenity in GS and an entheseal PD signal (≤2 mm from bone insertion). Results Sixty-four Pso patients and 21 HCs were included; globally 2816 joints and 768 entheses were scanned. Twenty-three out of 64 (35.9%) Pso patients displayed CA. Baseline characteristics are reported in table 1. Active synovitis was found, in at least one joint, in 20/64 (31.3%) Pso patients and 0/21 HCs (p=0.002), while active enthesitis in 14/64 (21.9%) Pso patients and 0/21 HCs (p=0.017). No significant differences were found for active synovitis or enthesitis between the two subgroups of Pso, with or without CA. In the Pso cohort, 5/23 (23.8%) patients with CA and 2/41 (5%) without CA displayed tenosynovitis or paratenonitis (p=0.042). Furthermore, active synovitis, as well as GS-synovitis ≥2, was associated with higher NAPSI (9.7±8.0 vs 4.6±7.1, p=0.04 for GS ≥2), whereas active enthesitis was associated with higher PASI (5.4±3.0 vs 3.7±2.9, p=0.02). No significant differences were found between Pso patients and HCs for the structural damage (i.e. osteoproliferation and erosions), both for joints and enthesis.Abstract SAT0304 – Table 1 * p significant Pso with CA vs HCs; ** p significant Pso with CA vs Pso without CA Conclusions In Psoriasis subclinical US active synovitis and/or enthesitis are present in 20%–30% of patients. In Pso the comparison between groups, with or without CA, show no significant difference in active subclinical synovitis or enthesitis, but Pso patients with CA present more frequently US tenosynovitis or paratenonitis. In Pso subclinical US synovitis or enthesitis are significantly associated with higher NAPSI and PASI. The relevance of these results, to possibly identify a subgroup of Pso more prone to develop PsA, deserve further investigation and prospective evaluation. Disclosure of Interest None declared

FRI0677 Role of nailfold videocapillaroscopy and 22-MHZ doppler ultrasound in the assessment of systemic sclerosis-related digital vasculopathy

Background Microvascular damage plays a critical role in the initiation and perpetuation of systemic sclerosis (SSc). A comprehensive approach should investigate both superficial and deep layers of peripheral microcirculation. In addition to nailfold videocapillaroscopy (NVC), a well-established technique to evaluate outer skin layer vessels, power Doppler ultrasound (PDUS) has been recently used to study microcirculation in the inner levels [1]. Objectives To study the severity of microvascular involvement in patients with SSc by using both NVC to measure capillary density (outer layer at the nailfold area) and PDUS to detect perfusion (deeper layers at the nailfold and pulp area). Methods 100 SSc consecutive patients fulfilling the 2013 EULAR classification criteria were enrolled. PDUS was performed at the 3rd and 4th finger of the dominant hand after exclusion of ulnar artery occlusion (UAO). In case of UAO non-dominant hand was examined. Ultrasound investigation was performed with Esaote MyLab 70 XVG by means of linear array transducer (10–22 MHz). Power Doppler settings were standardized (Doppler frequency 14.3 MHz, Gain 55%, PRF 750 Hz). PDUS measurements included sagittal scan of nailbed and fingertip qualitatively graded from 1 (no signal) to 4 (marked hyperemia) [2], and resistivity index (RI) of ulnar and radial proper digital arteries. Capillary density (number/mm) was calculated by NVC with magnification 200X performed on two images of the same digits examined by PDUS. Results 100 SSc patients, 87 (87%) women, 86 (86%) limited cutaneous SSc, median age 62.2 years old, median disease duration 8 years were evaluated. 7 (7%) patients had UAO. Concordance between fingertip and nailbed perfusion as assessed by PDUS is reported in Table 1.Table 1 Nailbed PDUS Sum Grade 1 Grade 2 Grade 3 Grade 4 Fingertip PDUS Grade 1 15 19 3 1 38 Grade 2 13 13 6 6 38 Grade 3 3 5 10 10 28 Grade 4 2 8 15 71 96 Sum 33 45 34 88 200 Concordance between fingertip and nailbed perfusion as assessed by PDUS is equal to 0.7398. The lower 97.5% confidence interval limit is 0.6433. Association between capillary density, and fingertip and nailbed perfusion as assessed by PDUS is shown in Table 2.Table 2 Capillary density p-value of the difference between the mean of the category, with respect to reference (grade 1) Fingertip PDUS  Grade 1 2.895  Grade 2 3.763 0.038  Grade 3 3.500 0.181  Grade 4 3.844 0.007 Nailbed PDUS  Grade 1 3.212  Grade 2 3.433 0.597  Grade 3 3.294 0.854  Grade 4 3.949 0.049 Conclusions To our knowledge, this is the first study to correlate NVC and PDUS finding in SSc patients. Fingertip and nailbed PDUS grade concordance was found to be satisfactory. The mean capillary density tends to be greater with respect to grade 1. This is particularly evident comparing grade 4 and grade 1. As such, these two imaging techniques provide different and potentially complementary information on SSc-related peripheral microvascular involvement. There is potential clinical utility in these observations that has yet to be unlocked fully. References Lescoat A et al. Arthritis Care Res. 2016;Epub ahead of print. Newman JS et al. Radiology. 1996,198:582–584. Disclosure of Interest None declared

OP0217 Ultrasound-Detected Synovitis and Tenosynovitis Independently Associate with Flare in Patients with Rheumatoid Arthritis in Clinical Remission

Background Remission is the target of treatment in rheumatoid arthritis (RA). In clinically-defined remission, subclinical disease activity may persist leading to flare and joint damage progression. Musculoskeletal ultrasonography (MSUS) is a good candidate to overcome the limitations of clinimetric indexes. The role of MSUS synovitis is well-known in the literature but no data are available for tenosynovitis. Objectives The study aims to evaluate the association between US synovitis (S) and tenosynovitis (T) and 6-month flare in RA patients in clinical remission. Methods The STARTER study is a multicentre cohort study promoted by the Italian Society for Rheumatology. Ultrasonographers were selected by an inter-reader reliability exercise. Consecutive patients with RA and clinical remission underwent a full clinical evaluation and Grey Scale (GS) and power Doppler (PD) US exam (assessing -S and -T) at wrists, MCP, PIP and extensor/flexor tendon sheets. Six-month flare was defined as: 1) increase of >1.2 or >0.6 if final DAS28>3.2; 2) change in treatment; 3) change of >4 points in the flare questionnaire (FQ) if FQ<4 at baseline. The relationships between presence of GS-T/-S, PD-T/-S were evaluated by logistic models, presented as odds ratios (OR) and 95%CI, adjusted for pre-specified confounders. Results A total of 427 patients were included in the analyses: 113 (26.5%) men, mean (SD) age 56.6 (13.4), median (IQR) disease duration 7.3 (3.8-13.5) years, median (IQR) remission duration 12 (8-24) months, RF positive 287 (67.4%), mean (SD) DAS28 2.2 (0.8), median (IQR) HAQ 0.125 (0-0.375), on DMARDs 322 (75.4%), on biologics 183 (42.9%), on glucocorticoids 187 (43.8%). GS-T was present in 198/373 (53.1%) patients, PD-T in 88/372 (23.7%) while GS-S in 270/368 (73.4%) and PD-S in 171/372 (46.5%). The association between US variables and flare is reported in the Table. Conclusions MSUS PD-S confirms its predictivity on flare defined according to DAS28 definitions while PD-T is more specifically associated with patient-related flare and symptoms exacerbation. US-T should be take into account in the management of RA patients in clinical remission. Disclosure of Interest None declared

OP0224 Th17 Cells and TFH Cells and their Cytokine Products Are Enriched in the Synovium of Rheumatoid Arthritis Patients and Correlate with Disease Activity

Background Rheumatoid arthritis (RA) and osteoarthritis (OA) patients are affected by joint degradation caused by autoimmune pathology and cartilage loss, respectively. The balance between effector and regulatory T cell subsets that secrete respectively IL-17 (Th17 cells), IL-21 and BAFF (follicular helper T cells, TFH) or IL-10 (Tr1 cells and Tregs) are thought to be crucial in RA pathology, while little is known on the role of these T cell subsets in OA. Objectives To monitor the frequency and function of T cell subsets in RA and OA patients in peripheral blood or affected tissue (synovial fluid and synovial membrane) and their cytokine products in serum and synovial fluid, and to correlate these parameters with disease activity. Methods Blood samples from 24 clinically well-characterized RA patients, 11 OA and 25 healthy donors (HD) were included. Additionally, synovial fluid as well as synovial membranes were analysed when available. Composition of different T cell subsets according to surface marker expression and intracellular cytokine production were assessed by flow cytometry. Cytokines in serum and secreted by T cell subsets were correlated with disease activity assessed as das28 index or the presence of autoantibodies. Synovial B cell IgG production was measured in the absence and presence of helper and regulatory T cell subsets by ELISA. Results Th17 cells were decreased in the peripheral blood of RA patients, while OA patients had surprisingly an altered ratio of CD25+Tregs and Tr1 cells in circulation. In synovial tissues Th17 cells, TFH and regulatory T cell subsets were enriched among CD4+ T cells in RA as compared to OA patients, while frequencies of Th1 cells were similar. RA patients had higher serum levels of IL-17, IL-10 and BAFF, while serum IL-21 was elevated in both RA and OA patients. Importantly, serum levels of IL-17, IL-10 and BAFF were enhanced only in patients with active RA or with detectable autoantibodies. Moreover, BAFF and IL-17 levels in synovial fluid were also higher in RA as compared to OA patients, while IL-10 concentrations were similar. B cells from synovial fluid spontaneously released high amounts of IgG in the absence of CD4+ helper T cells, and regulatory T cell subsets were unable to suppress B cell IgG production. Conclusions Th17 cells and TFH cells accumulate in synovial tissues of RA patients, and IL-17 and BAFF both in serum and synovial fluid correlate with disease activity, suggesting a role for TFH cells and/or Th17 cells in disease progression and autoantibody production. Moreover, although regulatory T cell subsets are efficiently recruited to the synovium they seem to be functionally impaired, since they failed to suppress B cell antibody production. Interestingly, also OA patients show a peculiar modulation of T cell subsets in peripheral blood, but in contrast to RA patients only the anti-inflammatory cytokine IL-10 is expressed in the synovium. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5392

AB0998 Medium and high molecular weight hyaluronic acid injected in hip joint by US-guided technique in patients with primary or secondary hip osteoarthritis: A 2 year observational study

Background Guidelines for treatment of osteoarthritis (OA) of the hip of the American College of Rheumatology provide intra-articular therapy with steroids and hyaluronic acid (HA) in addition to standard therapy. The hip joint is difficult to approach and several studies in the literature show greater safety and accuracy when the US-guided procedure is used. The HA used are different although high molecular weight (MW) HA allows smaller number of infiltrations. However, there are no data on the best administration schedule (i.e. number or intervals of infiltrations) and on the clinical characteristics of the patients in order to get the highest efficacy. Objectives To evaluate the efficacy and safety of medium and high MWHA injection in hip joint by US-guided technique with a follow up of 2 years. To study if there are negative predictive factor for this therapy. Methods 95 hips of 91 patients (45 M; 46 F), mean age 57,6±15,35, 80 primary hip OA, 15 hip OA secondary to inflammatory rheumatic diseases were randomly assigned to treatment with Hylan G-F 20 [Synvisc®-Genzyme] (56 hips), or Sodium Hyaluronate >1.6KDa [Hyalubrix®-Fidia] (39 hips), intra-articularly in the hip. The treatment consisted of three injections: at the inclusion, after 1 and 2 months; then the treatment was repeated every 6 months. Efficacy was assessed by pain evaluation on a 100mm VAS scale and WOMAC questionnaire for hip osteoarthritis recorded at the inclusion, after 1, 6, 12 and 24 months. Data on age, BMI, radiologic degree of OA (Kellgren-Lawrence scale) and duration of symptoms were also recorded at the inclusion. Viscosupplementation was performed with an anterior sagittal approach, under ultrasound guidance. Patient who had to recur to prosthesis up to six months after the end of the study were excluded. Friedman test for repeated measures with Bonferroni correction was used to test efficacy of the treatment. Multivariate logistic regression analisys was used to find if there were predictive indices for the response variables. Results The treatment produced a significant improvement on VAS pain and on WOMAC total score (p<0.0001) rapidly after 1 month maintained over 2 years independently from radiological degree of OA, independently from the type of HA used and present both in primary and secondary OA group. The improvement was faster in the group treated with higher MW HA that was showed by a significant improvement on VAS pain (p=0.039) between T0 and T1 in the higher MW group vs. medium MW group. Multivariate logistic regression analysis on age, disease duration, BMI and radiological degree didn’t showed any significance. However there was a trend towards significance that shows that patients non responder to treatment were older than average (p=0.08) and with higher BMI (p=0.09). Conclusions With our scheme of treatment there was an improvement on pain function immediately one month after intraarticular HA treatment that was maintained over the 2 years. In our study high MW Synvisc seems to be more rapid in the effect than medium MW Hyalubrix. Advanced age and higher BMI seems to be negative predictive factors for the result of the therapy, while radiological scoring is not. Further studies with larger numbers of patients and control arms are needed to confirm our results. Disclosure of Interest None Declared