P. Hanova

Ultrasound definition of tendon damage in patients with rheumatoid arthritis. Results of a OMERACT consensus-based ultrasound score focussing on the diagnostic reliability

Objective To develop the first ultrasound scoring system of tendon damage in rheumatoid arthritis (RA) and assess its intraobserver and interobserver reliability. Methods We conducted a Delphi study on ultrasound-defined tendon damage and ultrasound scoring system of tendon damage in RA among 35 international rheumatologists with experience in musculoskeletal ultrasound. Twelve patients with RA were included and assessed twice by 12 rheumatologists-sonographers. Ultrasound examination for tendon damage in B mode of five wrist extensor compartments (extensor carpi radialis brevis and longus; extensor pollicis longus; extensor digitorum communis; extensor digiti minimi; extensor carpi ulnaris) and one ankle tendon (tibialis posterior) was performed blindly, independently and bilaterally in each patient. Intraobserver and interobserver reliability were calculated by κ coefficients. Results A three-grade semiquantitative scoring system was agreed for scoring tendon damage in B mode. The mean intraobserver reliability for tendon damage scoring was excellent (κ value 0.91). The mean interobserver reliability assessment showed good κ values (κ value 0.75). The most reliable were the extensor digiti minimi, the extensor carpi ulnaris, and the tibialis posterior tendons. An ultrasound reference image atlas of tenosynovitis and tendon damage was also developed. Conclusions Ultrasound is a reproducible tool for evaluating tendon damage in RA. This study strongly supports a new reliable ultrasound scoring system for tendon damage.

Serum calprotectin (S100A8/9): an independent predictor of ultrasound synovitis in patients with rheumatoid arthritis.

IntroductionCalprotectin, a heterodimeric complex of S100A8/9 (MRP8/14), has been proposed as an important serum biomarker that reflects disease activity and structural joint damage in rheumatoid arthritis (RA). The objective of this cross-sectional study was to test the hypothesis that calprotectin is associated with clinical and ultrasound-determined disease activity in patients with RA.MethodsA total of 37 patients with RA (including 24 females, a mean disease duration of 20 months) underwent a clinical examination and 7-joint ultrasound score (German US-7) of the clinically dominant hand and foot to assess synovitis by grey-scale (GS) and synovial vascularity by power Doppler (PD) ultrasound using semiquantitative 0–3 grading. The levels of serum calprotectin and C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were determined at the time of the ultrasound assessment. We analysed the relationship between serum calprotectin level, traditional inflammatory markers, and ultrasound-determined synovitis.ResultsThe levels of serum calprotectin were significantly correlated with swollen joint count (r = 0.465, p < 0.005), DAS28-ESR (r = 0.430, p < 0.01), ESR (r = 0.370, p < 0.05) and, in particular, CRP (r = 0.629, p < 0.001). Calprotectin was significantly associated with GS (r = 0.359, p < 0.05) and PD synovitis scores (r = 0.497, p < 0.005). Using multivariate regression analysis, calprotectin, adjusted for age and sex, was a better predictor of PD synovitis score (R2 = 0.765, p < 0.001) than CRP (R2 = 0.496, p < 0.001).ConclusionsThe serum levels of calprotectin are significantly associated with clinical, laboratory and ultrasound assessments of RA disease activity. These results suggest that calprotectin might be superior to CRP for monitoring ultrasound-determined synovial inflammation in RA patients.

The OMERACT Ultrasound Working Group 10 Years On: Update at OMERACT 12

Musculoskeletal ultrasound (US) now thrives as an established imaging modality for the investigation and management of chronic inflammatory arthritis. We summarize here results of the Outcome Measures in Rheumatology (OMERACT) US working group (WG) projects of the last 2 years. These results were reported at the OMERACT 12 meeting at the plenary session and discussed during breakout sessions. Topics included standardization of US use in rheumatic disease over the last decade and its contribution to understanding musculoskeletal diseases. This is the first update report of WG activities in validating US as an outcome measure in musculoskeletal inflammatory and degenerative diseases, including pediatric arthritis, since the OMERACT 11 meeting.

Serum Calprotectin Discriminates Subclinical Disease Activity from Ultrasound-Defined Remission in Patients with Rheumatoid Arthritis in Clinical Remission

Objective Clinical remission in some patients with rheumatoid arthritis (RA) may be associated with ongoing synovial inflammation that is not always detectable on clinical examination or reflected by laboratory tests but can be visualized by musculoskeletal ultrasound. The goal of our study was to determine the levels of serum calprotectin, a major leukocyte protein, in patients with RA in clinical remission and to investigate the ability of serum calprotectin levels to distinguish patients in ultrasound-defined remission from those with residual ultrasound subclinical inflammation. Methods Seventy RA patients in clinical remission underwent clinical and ultrasound examination. Ultrasound examination was performed according to the German US7 score. Ultrasound remission was defined as grey scale (GS) range 0–1 and power Doppler (PD) range 0. The levels of serum calprotectin and C-reactive protein (CRP) were determined. The discriminatory capacity of calprotectin and CRP in detecting residual ultrasound inflammation was assessed using ROC curves. Results The total number of patients fulfilling the DAS28-ESR, DAS28-CRP, SDAI and CDAI remission criteria was 58, 67, 32 and 31, respectively. Residual synovial inflammation was found in 58–67% of the patients who fulfilled at least one set of clinical remission criteria. Calprotectin levels were significantly higher in patients with residual synovial inflammation than in those with ultrasound-defined remission (mean 2.5±1.3 vs. 1.7±0.8 μg/mL, p<0.005). Using ultrasound-defined remission criteria, calprotectin had an AUC of 0.692, p<0.05 using DAS28-ESR remission criteria and an AUC of 0.712, p<0.005 using DAS28-CRP remission criteria. Calprotectin correctly distinguished ultrasound remission from subclinical activity in 70% of patients. CRP (AUC DAS28-ESR = 0.494, p = NS; AUC DAS28-CRP = 0.498, p = NS) had lower and insignificant discriminatory capacity. Conclusion The present study demonstrates the potential of calprotectin to distinguish RA patients in both clinical and ultrasound-defined remission from patients in clinical remission but with residual subclinical disease activity.

Definitions and reliability assessment of elementary ultrasound lesions in giant cell arteritis: a study from the OMERACT Large Vessel Vasculitis Ultrasound Working Group

Objectives To define the elementary ultrasound (US) lesions in giant cell arteritis (GCA) and to evaluate the reliability of the assessment of US lesions according to these definitions in a web-based reliability exercise. Methods Potential definitions of normal and abnormal US findings of temporal and extracranial large arteries were retrieved by a systematic literature review. As a subsequent step, a structured Delphi exercise was conducted involving an expert panel of the Outcome Measures in Rheumatology (OMERACT) US Large Vessel Vasculitis Group to agree definitions of normal US appearance and key elementary US lesions of vasculitis of temporal and extracranial large arteries. The reliability of these definitions on normal and abnormal blood vessels was tested on 150 still images and videos in a web-based reliability exercise. Results Twenty-four experts participated in both Delphi rounds. From originally 25 statements, nine definitions were obtained for normal appearance, vasculitis and arteriosclerosis of cranial and extracranial vessels. The ‘halo’ and ‘compression’ signs were the key US lesions in GCA. The reliability of the definitions for normal temporal and axillary arteries, the ‘halo’ sign and the ‘compression’ sign was excellent with inter-rater agreements of 91–99% and mean kappa values of 0.83–0.98 for both inter-rater and intra-rater reliabilities of all 25 experts. Conclusions The ‘halo’ and the ‘compression’ signs are regarded as the most important US abnormalities for GCA. The inter-rater and intra-rater agreement of the new OMERACT definitions for US lesions in GCA was excellent.

Relationship between serum calprotectin (S100A8/9) and clinical, laboratory and ultrasound parameters of disease activity in rheumatoid arthritis: A large cohort study

Background Calprotectin may be a sensitive biomarker of rheumatoid arthritis (RA) disease activity. Objectives In the current study, we investigated whether calprotectin is a better biomarker than CRP for predicting clinical activity and ultrasound parameters in patients with RA. Methods A total of 160 patients with RA underwent clinical (swollen joint count—SJC, tender joint count—TJC, Disease Activity Score—DAS28, Clinical Disease Activity Index—CDAI, and simplified Disease Activity Index—SDAI) and ultrasound (German US7) examination. Clinical and laboratory measures were correlated with ultrasound findings using Spearman´s correlation coefficient. Differences in serum calprotectin levels in patients with variable disease activity according to the DAS28-ESR and CDAI scores were assessed using ANOVA. Multivariate regression analysis was used to determine the predictive values of calprotectin, CRP and SJC for CDAI and PD US synovitis scores. Results Serum calprotectin was significantly associated with DAS28-ESR (r = 0.321, p<0.001), DAS28-CRP (r = 0.346, p<0.001), SDAI (r = 0.305, p<0.001), CDAI (r = 0.279, p<0.001) scores and CRP levels (r = 0.556, p<0.001). Moreover, calprotectin was significantly correlated with GS (r = 0.379, p<0.001) and PD synovitis scores (r = 0.419, p<0.001). The multivariate regression analysis showed that calprotectin is a better predictor of the CDAI score and PD US synovitis than CRP. Conclusions The results of this study support an additional role of calprotectin in assessing inflammatory activity in patients with RA.

AB0239 Development of a novel „molecular disease activity“ tool composed of 8 serum biomarkers for monitoring rheumatoid arthritis

Background Accurate disease activity measurement is a key component of rheumatoid arthritis (RA) management. In 2012, multi-biomarker disease activity (MBDA) test using 12 serum proteins was presented1. Objectives To develop a novel test for measuring inflammatory activity in RA. Methods Serum samples were obtained from 82 patients with RA (60 females, median disease duration 4.2 years, median age 55.2 years, RF positivity 60.3%, ACPA positivity 69.7%). A detailed stepwise analysis of 20 candidate biomarkers selected from the literature search (IL1β, IL-6, IL-7, IL-8, IL-12p70, IL-17A, IL-22, IL-33, IL-34, IFNγ, VEGF, YKL-40, CXCL-13, MMP-3, resistin, visfatin, leptin, adiponectin, calprotectin and CRP) was performed. Methods of factor analysis (a statistical method used to describe variability among observed, correlated variables in terms of a potentially lower number of unobserved variables called factors) were used in order to develop a tool composed of different serum markers that would optimally reflect disease activity in RA. Spearman correlation index was used to explore associations between newly designed tool and clinical as well ultrasound parameters (German US7 score) of disease activity. Results We have developed a “Molecular Disease Activity” test covering underlying pathophysiological processes composed of 8 serum markers: calprotectin, CRP, IL-6, MMP-3, VEGF, resistin, IL-22 and IL-7 that optimally reflected inflammatory activity in RA. This model was significantly associated with clinical (DAS28-ESR, DAS29-CRP, CDAI, SDAI) and ultrasound variables (PD syn score, GS syn score) of disease activity in RA, as shown in table 1.Abstract AB0239 – Table 1 Cross-sectional correlations between “Molecular Disease Activity” tool composed of 8 biomarkers and clinical and ultrasound parameters of disease activity Parameters Molecular disease activity(factor score) p (significance) DAS28-ESR 0.664** <0.001 DAS28-CRP 0.666** <0.001 SDAI 0.731** <0.001 CDAI 0.669** <0.001 SJC 0.546** <0.001 GS syn score 0.657** <0.001 PD syn score 0.701** <0.001 ** Correlation is significant at≤0.01 CDAI, Clinical Disease Activity Index; DAS28-CRP, Disease Activity Score with C-reactive protein; DAS28-ESR, Disease Activity Score with erythrocyte sedimentation rate; GS syn, Grey Scale synovitis; PD syn, Power Doppler synovitis; SDAI, Simplified Disease Activity Index; SJC, swollen joint count Conclusions We believe that this newly designed test based on 8 serum markers may contribute to more accurate measurement of inflammatory activity in RA and improvement of patients‘ outcomes. Further evaluation of this tool in a larger cohort is needed. Reference [1] Centola M, Cavet G, Shen Y, et al. Development of a Multi-Biomarker Disease Activity Test for Rheumatoid Arthritis. Plos One2013Apr 9;8(4). Acknowledgements Supported by the project of Ministry of Health, Czech Rep. No. 0 23 728 and SVV No. 260 373. Disclosure of Interest None declared

02.30 High levels of mir-451a differentiate patients with clinically suspect arthralgia from healthy controls

Background Individuals with clinically suspect arthralgia (CSA) with positivity of anti-citrullinated protein antibodies (ACPA) are considered at high risk of developing rheumatoid arthritis (RA). The altered expression of miRNAs is involved in the development and maintenance of autoimmune diseases. We aimed to investigate differentially expressed miRNAs in peripheral blood mononuclear cells (PBMC) in CSA and healthy controls (HC). Material and methods The study included 19 CSA and 20 HC. Disease activity assessments and ultrasound of 28 small joints was performed in CSA. Total RNA from PBMC was isolated. A comprehensive analysis of miRNAs was performed using TaqMan Low Density Array (TLDA) in 5 samples per group. Single assay analysis of miR-451a, CXCL16 and IL-8 was performed in remaining samples and normalised to RNU44 or ACTB, respectively. dCt was used for relative quantification. Results TLDA analysis revealed 2.43x higher levels of miR-451a in CSA compared to HC. Further validation next confirmed 3.19x higher expression of miR-451a in CSA (p≤0.001). CXCL16 and IL-8 were predicted as miR-451a targets. Expression of miR-451 positively correlated with CXCL16 (r=0.497; p=0.030) in CSA and IL-8 in both CSA (r=0.485; p=0.035) and HC (r=0.617; p=0.004). This is suggestive of an indirect regulation by miR-451 and a specific role of CXCL16 in CSA. Moreover, the expression of both CXCL16 (1.51x; p=0.013) and IL-8 (3.17x; p=0.032) was higher in CSA compared to HC. By definition, all CSA individuals had swollen joint count 0. Ten CSA had some degree of subclinical activity on ultrasound (GC>1/PD>0). Levels of miR-451 significantly correlated with DAS28-CRP (r=0.575; p=0.010), SDAI (r=0.676; p=0.004) and VAS (r=0.484; p=0.036). CXCL16 correlated with tender joint count (r=0.576; p=0.010). Subclinical activity as per US had no effect on the levels of miR-451a, CXCL16 or IL-8 in PBMC. Conclusions Although CSA cannot be considered a disease itself, and is rather a clinical suspicion of a disease, high levels of miR-451a in PBMC distinguish these individuals at high risk of developing RA. Moreover, miR-451 in PBMC reflects the activity at this pre-clinical phase and correlates with CXCL16 with a role in angiogenesis and chemotaxis. Acknowledgement Projects MHCR 023728, SVV 2 60 263.

FRI0532 Association between The 7-Joint Ultrasound Score (US7S) and Physical Function in Rheumatoid Arthritis

Objectives To investigate the longitudinal relationship between physical disability and US7S in a prospective cohort of patients with RA. Methods A cohort of 205 RA pts (49 incident/156 prevalent) (mean±SD age 55±14 years, 47% RF+, 63% ACPA+, DAS28-CRP 3.7±1.5, mHAQ 0.43±0.52, disease duration in incident vs. prevalent pts. 0.9±0.7 vs. 8.1± 8.3 resp.) was followed up longitudinally for 29±9 months. Assessments at baseline and at month 3 and 6, and then every 6 months comprised DAS28-CRP, functional evaluations using the modified Health Assessment Questionnaire (mHAQ) and an ultrasound assessment of the clinically dominant hand and foot by US7S1. US7S consists of 5 subscores for synovitis (syn) and tenosynovitis (ten) assessed by grey-scale (GS) and Power-Doppler (PD), and an erosions score (ES). A linear mixed model was used to assess the longitudinal relationship between US7 subscores and mHAQ. Univariate analyses with an interaction term for incident vs. prevalent disease, and a multivariate analysis (with age, sex, BMI, RF and ACPA status, and DAS28-CRP entered as covariates) were performed. Results In univariate analyses (table) mHAQ was longitudinally associated with GSsyn, PDsyn, PDten and GSten US7 subscores (with resp. β coefficients significantly higher in incident patients), while erosions score was a significant predictor of mHAQ only in prevalent pts. In a multivariate model the US7 subscores were individually no longer significant predictors of mHAQ, although the R2 of the model was improved by addition of US7 items from 43.6 to 46.9 (p<0.001 for improvement of R2).Table 1. Univariate analyses and interaction with incident (i)/prevalent (p) RA (predicted variable – mHAQ) Predictor RA β (95% CI) p-value* p-value** % variability explained – R2 DAS28-CRP all 0.112 (0.100; 0.123) <0.001 0.510 44.5 i 0.120 (0.093; 0.146) <0.001 p 0.110 (0.097; 0.123) <0.001 GSsynUS all 0.008 (0.004; 0.011) <0.001 0.038 3.2 i 0.014 (0.007; 0.021) <0.001 p 0.006 (0.002; 0.010) 0.002 PDsynUS all 0.012 (0.008; 0.016) <0.001 0.018 4.3 i 0.021 (0.012; 0.029) <0.001 p 0.009 (0.004; 0.014) <0.001 GStenUS all 0.018 (0.002; 0.035) 0.032 0.078 1.7 i 0.045 (0.011; 0.080) 0.010 p 0.010 (0.000; 0.020) 0.316 PDtenUS all 0.024 (0.012; 0.037) <0.001 0.032 2.0 i 0.053 (0.024; 0.083) <0.001 p 0.017 (0.010; 0.024) 0.013 ES all 0.009 (−0.003; 0.021) 0.145 0.062 0.3 i −0.021 (−0.055; 0.013) 0.216 p 0.013 (0.001; 0.026) 0.047 *p-value of significance of given β. **p-value of significance of difference between incident and prevalent RA. Conclusions This study provides evidence that RA related activity and damage reflected by US7S contribute to impaired physical function in RA, and their impact differs in early and established disease. When combined with conventional clinical parameters, the additional explanatory value of US7 for mHAQ was only minor. References Backhaus M. et al. Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project. Arthritis Rheum. 2009 Sep 15;61(9):1194–201 Acknowledgement This work was supported by the project (Ministry of Health, Czech Republic) for consensual development of research organization 023728, and IGA grant NT12437 Disclosure of Interest None declared

A3.10 Serum calprotectinis elevated in patients with early rheumatoid arthritis but not in patients at risk of developing rheumatoid arthritis

Background and objectives Calprotectin (S100A8/S100A9 complex) is associated with disease activity, radiographic progression and may predict treatment response in patients with rheumatoid arthritis (RA). The aim of our study was to examine the serum levels of calprotectin in clinically suspect arthralgia patientswith positive antibodies to citrullinated peptide antigens (ACPA) who areat high risk of developing RA. Materials and methods This cross-sectional study included 20 ACPA+ arthralgiapatients, 55 patients with early RA (disease duration <6 months who fulfilled 2010 ACR/EULAR classification criteria) and 68 healthy controls (HC). Disease activity was assessed using DAS28. Ultrasound of 28 small joints was performed in all patients with arthralgia to evaluate subclinical synovitis. Serum calprotectin levels were determined byELISA. Data were analysed using 1way ANOVA, Mann-Whitney test and Spearman’s and Pearson’s correlation coefficients. The data are expressed as mean±SD. Results Patients with clinically suspect arthralgia showed no clinical and ultrasound evidence of arthritis (grey scale and power Doppler for single joint ≤ 1). Of these, all were ACPA+, 70%females; age 41.92 ± 11.72 years, CRP 7.39 ± 19.19 mg/l. Treatment naïve patients with early RA had active disease (meanDAS28:5.54 ± 1.62), 65% were ACPA+, 71% were females; age 54.17 ± 16.77 years and CRP 20.46 ± 26.66 mg/l. Serum calprotectin in clinically suspect ACPA+ arthralgia patientswas not significantly different compared to HC (2980 ± 1610 vs. 3368 ± 1624 ng/ml, p = 0.35) but was significantly lower in both groups compared to early RA (5977 ± 5787 ng/ml, p = 0.01 and 0.02 respectively). There was no correlation between calprotectin and CRP in suspect arthralgia patients, however, in early RA, serum calprotectin significantly correlated with DAS28 (r = 0.432, p = 0.001) and CRP (r = 0.670, p < 0.0001). Conclusions Calprotectin is not increased in ACPA positive patients who have normal ultrasound findings of small joints and thus may not help to predict RA development in this early stage of the disease. However, calprotectin is significantly elevated in patients with active early RA, where it serves as a reliable biomarker of disease activity. Acknowledgements IGA project no. NT 14498, project of MHCR 023728 and project SVV 260 155.