V. Di Sabatino

Ultrasound in the diagnosis of calcium pyrophosphate dihydrate deposition disease. A systematic literature review and a meta-analysis

OBJECTIVE Ultrasonography (US) demonstrated to be a promising tool for the diagnosis of calcium pyrophosphate dihydrate deposition disease (CPPD). The aim of this systematic literature review (SLR) was to collect the definitions for the US elementary lesions and to summarize the available data about US diagnostic accuracy in CPPD. METHODS We systematically reviewed all the studies that considered US as the index test for CPPD diagnosis without restrictions about the reference test or that provided definitions about US identification of CPPD. Sensitivity and specificity were calculated for each study and definitions were extrapolated. Subgroup analyses were planned by anatomical site included in the index text and different reference standards. RESULTS Thirty-seven studies were included in this review. All the studies were eligible for the collection of US findings and all definitions were summarized. US description of elementary lesions appeared heterogeneous among the studies. Regarding US accuracy, 13 articles entered in the meta-analysis. Considering each joint structure, the sensitivity ranged between 0.77 (0.63-0.87) and 0.34 (0.16-0.58) while the specificity varies between 1.00 (0.89-1.00) and 0.92 (0.16-1.00). Considering the reference standards used, the sensibility ranged between 0.34 (0.02-0.65) and 0.87 (0.76-0.99) while specificity ranged between 0.84 (0.52-1.00) and 1.00 (0.99-1.00). CONCLUSION US is potentially a useful tool for the diagnosis of CPPD but universally accepted definitions and further testing are necessary in order to assess the role of the technique in the diagnostic process.

Prevalence of Baker’s cyst in patients with knee pain: an ultrasonographic study

The objectives of this study are to investigate the prevalence of Bakers cyst (BC) in patients with knee pain, and to assess the correlation between BC and severity of osteophytes and joint effusion. A retrospective study was conducted on a group of patients with knee pain referred to our outpatient clinic for ultrasonography of the knee between January 2010 and February 2011. Patients underwent an ultrasonographic exam of the knees to assess the presence of marginal femorotibial osteophytosis, joint effusion and BC. A dichotomous score was assigned to each item (1 present, 0 absent) and severity of US signs of osteoarthritis and joint effusion were also graded semiquantitatively. Collected data were processed using logistic regression analysis to evaluate the correlation between degree of osteophytosis and joint effusion and BC. Patients affected by inflammatory joint conditions or with history of joint surgery or recent trauma were excluded. A total of 399 patients with knee pain were studied (299 women), in the age range 18-89 years (mean 56.2, SD 16.3 years). 293 patients (73.4%) showed sonographic features of osteoarthritis and 251 (62.9%) joint effusion. BC was found in 102 patients (25.8%) together with a positive association with sonographic features of osteoarthritis and joint effusion. Our data show a prevalence of BC of 25.8% in a population of patients with knee pain, and suggest that BC is positively related to osteoarthritis and joint effusion. Ultrasonographic examination of knee is worthwhile in patients with painful osteoarthritis or evidence of effusion.

Chronic pelvic pain: comorbidity between chronic musculoskeletal pain and vulvodynia.

Chronic pelvic pain (CPP) is a common condition that has a major impact on the quality of life of both men and women. Male CPP is usually attributable to well-defined urogenital conditions (most frequently infectious/non infectious prostatic diseases) or musculoskeletal or bowel diseases, whereas the features of female CPP are much more complex and are of particular clinical and epidemiological importance. It is a multifactorial syndrome that can be due to diseases of the urogenital, gastrointestinal, or musculoskeletal systems, or to neurological or neuropsychiatric disorders. It is not always easy to identify its predominant pathogenesis, although it often occurs as a central sensitization syndrome triggered by an initial stimulus which is no longer detectable and only manifests itself clinically through pain. In this respect, there are some very interesting relationships between vulvodynia and fibromyalgic syndrome, as identified in a preliminary study of women with chronic musculoskeletal pain in which it was demonstrated that vulvar pain plays an important role, although it is often overlooked and undiagnosed.

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

Change perspective to increase diagnostic accuracy of ultrasonography in calcium pyrophosphate dehydrate deposition disease! A new approach: the axial scan of the meniscus.

Ultrasonography (US) is a relevant tool in the study of calcium pyrophosphate dihydrate (CPP) deposition disease. However, differential diagnosis of hyperechoic deposits within the fibrocartilage can be difficult; moreover, US study is limited by the need of an adequate acoustic window. We describe a US scanning technique that offers a new viewpoint in the study of knee meniscal structure: a longitudinal scan performed according to the long axis of meniscus. This technique proves to be particularly useful for the identification of CPP deposition, but could also improve the US diagnostic utility and accuracy in other meniscal pathologies.

Radiologists and rheumatologists on performing and reporting shoulder ultrasound: from disagreement to consensus

Shoulder pain is a common condition in the rheumatologists practice, yet there are no guidelines on how to report shoulder ultrasound (US) examinations. The aim of this study was to compare scanning and reporting techniques performed by radiologists and rheumatologists and identify any discrepancies between the two. The participants in this study were five rheumatologists and two radiologists specialized in musculoskeletal US. The study was divided in 2 phases. In the first phase, each participant performed an US of 3 patients and reported the findings without knowing the patient diagnosis and the findings reported by the other operators. Other three investigators reported the US technique of each operator. Reports and images were subsequently compared to identify any discrepancies and reach consensus on a common approach. In the second phase, a US scan was performed on a fourth patient in a plenary session to assess feasibility and efficacy of the common approach The US scanning technique was similar for all operators. The differences in reporting emerged in the description of the rotator cuff disease. Radiologists provided a detailed description of lesions (measurements along 2 axis and scoring of lesions), whereas rheumatologists described carefully the inflammatory changes. The experts concluded that lesions should be measured along 2 axes and the grade of degeneration and the age of the lesion should be reported. Another difference emerged in the description of the irregularities of the bone surface. The experts concluded that the term erosion should be used only when an inflammatory joint disease is suspected. This study led to the clarification of some inconsistencies in US reporting, and represented an interesting collaborative experience between radiologists and rheumatologists.

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

SAT0625 Ultrasound assessment of joints and enthesis in a cohort of patients affected by ochronosis: how common is inflammation?

Background Ochronosis, the musculoskeletal manifestation of alcaptonuria (AKU), is characterized by alterations of the spine and large joints of the limbs similar to those of osteoarthritis. However, some cases of spinal involvement that resembles spondiloarthritis (SpA) have been describe, suggesting a prevalent inflammatory involvement of the joints. Objectives To evaluate the prevalence of inflammatory abnormalities in peripheral joints and enthesis of a cohort of patients affected by AKU. Methods consecutive patients with definite diagnosis of AKU (with or without clinical manifestations) referred at our clinic from 2014 to 2016 were enrolled. All patients underwent a US examination of the following sites bilaterally: metacarpo-phalangeal joints (MCP), proximal interphalangeal joints (PIP), radiocarpal/mid carpal joints, elbow, gleno-humeral, hip, knee, ankle and metatarso-phalangeal (MTP) joints; flexor and extensor tendons of fingers and wrist and the ankle tendons. Further, the enthesis of the rotator cuff of the shoulder, triceps, quadriceps, patellar and Achilles tendon were assessed. Joints and tendons with a synovial sheath were assessed for effusion, synovial hypertrophy and power Doppler (PD) signal while enthesis were evaluated for the presence of PD signal, enthesophytes and calcifications. All the US lesions were scored using a dichotomous scale (presence/absence). All US exams were performed by an expert sonographer blind to clinical history, using an Esaote MyLab70 scanner equipped with high resolution linear probes. Results 11 patients (6 women) were enrolled in this study with a mean age of 57 yo (SD±11,50). the mean number of joints with effusion was 3,9 for each patient (median 3, range 2–8) while the mean number of joints with synovial hypertrophy was of 2,9 (median 2, range 2–7). =0,18 joints (median 0, range 0–2) presented also PD signal. I The mean number of exudative tenosynovitis was0,81 (median 2, range 0–3) while proliferative tenosynovitis (mean 0,54, median 0, range 0–2) and PD in tendons with sheaths (mean 0,27, median 0, range 0–2) were rare. Finally, the mean number of enthesis with PD was 1,27 (median 1, range 0–7), the mean number of enthesophytes was 0,63 (median 0, range 0–3) and for calcifications 4,27 (median 5, range 1–8). Conclusions Ochronotic arthropathy is believed to be characterized by a widespread articular damage, correlated mainly to degenerative processes due to the deposition of Homogentisinic Acid in the joints. The results of this US study showed that joint inflammation is common in ochronotic patients, associated in some cases with peripheral enthesis involvement confirming previously published data (1). The prevalence and the characteristics of the inflammatory manifestations should be further studied in larger cohorts of patients as they could play an important role in the joint damage process in these patients and provide a rationale for the use of new drugs. References Filippou G, Frediani B, Selvi E et al, Tendon involvement in patients with ochronosis: an ultrasonographic study. Ann Rheum Dis 2008 Dec;67(12):1785–6. Disclosure of Interest None declared

SAT0542 The Prevalence of Calcium Pyrophosphate Deposits at Ultrasound Examination: Retrospective Analysis in A Cohort of Patients

Background The Calcium Pyrophosphate Deposition Disease (CPPD) is a disease frequently observed in the clinical practice but currently its exact prevalence is unknown. In fact, the data available in the literature vary depending on method used, generally x-ray or synovial fluid analysis, while no studies evaluated the ultrasound (US) prevalence of Calcium Pyrophosphate (CPP)deposits. Objectives The evaluation of the prevalence of CPP deposits in a cohort of patients (pt) that undergo US examination of wrists and knees. Methods We extracted from our database all reports of pt undergoing US exam of wrists and knees, referred to our outpatient clinic from October 2005 to January 2015. All US exams were performed by rheumatologists expert in muscoloskeletal ultrasound (MSUS) using an Esaote MyLab70 equipped with a 4–13 MHz linear probe. We recorded the presence of CPP deposits at the medial meniscus (MM), the lateral meniscus (LM) and the hyaline cartilage (HC) in the knees and at the triangular fibrocartilage (TF) of the wrists. Statistical analysis was performed with SPSS. Results US reports of 984 pt (81,9% female, mean age 50,28 SD±17,22) were included in this study. The overall prevalence of CPP deposits was 6,6% (65/984pt). In this group, the CPP deposits were observed in the 32,3% (21/65pt) of the wrists (bilaterally 61,9%) and in the 93,8% (61/65pt)of the knees (bilaterally 67,21%). The involvement of both joints were observed in the 26,15% (17/65pt). Analysing the prevalence by ages, it was 2,1% (14/664pt) in pt under 60 years old (yo), while it increased to 16,7% (51/306pt) in pt over 60. The prevalence was 8,7% (16/184pt) between 60 and 70 yo, 26,7% (24/90pt) between 70 and 80 yo, and increased to 34,4% (11/32pt) in pt over 80. Regarding the different joint structures, the prevalence was 89,2% (58/65pt) in menisci, (83,1% MM, 78,5% LM) and 32,3% (21/65pt) in the HC. The TF was involved in 32,3% of cases (21/65pt). Thus, according to previous studies1, our results showed that menisci, particularly MM, are the most involved by CPPD, appearing as the favorite site for US identification of CPP deposits. Moreover, this study confirmed the correlation between the aging and the increased prevalence of CPP deposits. However, our analysis showed a higher prevalence respect to the values obtained in previous studies that considered the x-ray as the reference method2. However, this trend should be further confirmed with a prospective assessment conducted in a larger sample of patients. Conclusions To our knowledge this is the first attempt to define the CPPD prevalence with US, that recently entered in EULAR recommendations as a promising diagnostic tool for CPPD3. Considering its accuracy, non-invasiveness and low cost, the US could be widely used for CPPD diagnosis also for large scale evaluation, planned in order to define the prevalence of this disease. References Filippou G et al Extent and distribution of CPP deposits in patients affected by calcium pyrophosphate dihydrate deposition disease: an ultrasonographic study. Ann Rheum Dis 2013 Ciancio G et al Epidemiology of gout and chondrocalcinosis. Reumatismo 2011 Zhang W et al European League Against Rheumatism recommendations for calcium pyrophosphate deposition. Part I: terminology and diagnosis. Ann Rheum Dis 2011 Disclosure of Interest None declared

SAT0564 Articular Involvement in Behçet Disease: An Ultrasonographic Study

Background An articular involvement is reported in Behçet disease up to 70% of patients, varying from referred arthralgia to arthrtitis, generally non-erosive, poly- or oligoarticular. Some authors compared this joint involvement to Seronegative Spondyloarthritis, reporting prevalent involvement of entheses and sacroiliitis. Few US studies has been conducted in Behçet, focusing on tendon and enthesal evaluation Objectives To evaluate the presence of US pathological findings of joints, tendons and entheses of patients affected by Behçet disease Methods We enrolled consecutive patients with Behçet disease reaching the Rheumatologic Unit of our hospital between Feb 2014 and Jan 2016, irrespective of disease activity status and therapy. US exams was performed by a single operator with 8–18 MHz linear transducers (Esaote MyLab70). 42 joints (shoulders, elbows, wrists, MCPs, PIPs, hips, knees, ankles, MTPs), 12 entheses (triceps tendons,common extensor tendons, knee entheses, Achilles tendons) and 20 tendon sheats (flexor digitorum tendons, wrists flexor and extensor tendons, anterior and posterior tibialis and peroneal tendons) were evaluated for each patient, using a stardardized technique. Grey scale (GS) and power Doppler (PD) US exam was performed to detect joint effusion, synovial hypertrophy and PD, classified with dicotomic and semiquantitative score (grade 0–3); effusion and synovial hypertrophy were combined in a single score and defined as synovitis. The presence/absence of tenosynovitis was evaluated for each site. At the entheseal level, we evaluated the presence of GS abnormalities of tendon structure (hypoechogenicity/thickness), enthesophytes and Doppler signal within the tendon or at the entheseal site, all classified as present/absent Results We evaluated a total amount of 1596 joints, 760 tendons and 456 entheses from 38 patients (20 women). A grade 1 synovitis was observed in 158 joints (9,9%): 87 MTPs, 21 knees, 19 MCPs, 14 wrists, 11 ankles, 4 PIPs and 2 elbows; in 72 patients the finding was monolateral while in 43 patients it was observed bilaterally, notably at I and II MTPs and knees joints. A grade 2 synovitis was observed in 18 joints (1,12%): 16 MTPs, 1 knee and 1 MCP; no grade 3 synovitis was observed. A grade 1 PD was detected in 2 wrists, 2 MCPs and 7 MTPs joints and a grade 3 PD was observed in a single MCP joint. We observed the presence of tenosynovitis in 36 cases, all involving hand or wrist tendon structures. 12 entheses presented altered fibrillar pattern with hypoecogenicity (8 common extensor tendons and 4 knee entheses), while the presence of enthesophytes was observed at the common extensor in 4 cases, at triceps in 8, at quadriceps in 6, at proximal patellar insertion in 2, at Achilles tendon in 21; the presence of at least 1 grey scale abnormality was observed in 63 entheseal sites (13,81%). An intratendineous PD signal was observed in 27 cases (5,9%): 16 common extensor tendons, 4 quadriceps, 3 proximal patellar insertion, 4 Achilles tendons Conclusions In a population of patients with Behçet disease we observed the presence of joint effusion in 11% and PD signal in 0,7% of examined joints, notably involving hands and feet joints. GS alteration of tendon structure was detected in 13,81% and an intratendineous PD signal in 5,9% of entheseal sites.A mild tenosynovitis was observed in 4,7% of examined tendons Disclosure of Interest None declared