OP0082 DISCORDANCE BETWEEN DAS28ESR AND PRESENCE OF ULTRASOUND POWER DOPPLER DURING EARLY TREATMENT IS ASSOCIATED WITH DISTINCT CLINICAL AND IMAGING PHENOTYPES AT PRESENTATION

Background

Discordance between DAS28ESR and musculoskeletal ultrasound (MSUS) detected power Doppler synovitis (PDUS) is well-recognised and may lead to under/overtreatment. We hypothesize that clinical and imaging features at diagnosis associate with early discordance of DAS28-PDUS and change in DAS28-PDUS status following DMARD treatment.

Objectives

To identify pre-treatment clinical factors associated with discordance and change in DAS28-PDUS status during early treatment in an early RA trial cohort.

Methods

The ‘VEDERA’ trial1 randomised 120 treatment-naïve, new-onset RA patients to either first-line etanercept + methotrexate (ETN+MTX) or methotrexate treat-to-target (MTX-TT) regime with escalation to ETN+MTX if not in DAS28ESR remission at week 24. Clinical and MSUS assessments were completed at baseline, weeks 12, 24 and 48. DAS28ESR ≤ 2.6 and DAS28ESR > 2.6 categorised remission and active disease respectively. PDUS presence was defined as total PDUS score ≥ 1. Active concordance (AC) was defined as active disease with PDUS while active discordance (AD) was defined as active disease without PDUS. Remission concordance (RC) was defined as DAS28ESR remission without PDUS while remission discordance (RD) was defined as DAS28ESR remission with PDUS. Bayesian multinomial logistic regression (posterior estimate and 95% credible intervals reported) was used to address the study objectives with AC as the comparator group.

Results

At baseline all patients had active disease (moderate or high DAS28ESR) in line with trial eligibility - 68% (81/120) were AC and 32% (39/120) were AD. Compared to AD patients, AC patients were older (median age 53 vs 44), had higher DAS28ESR (5.90 vs 5.16) and CRP (11.6mg/L vs 3.6mg/L), as well as a higher presence of greyscale (GS - 100% vs 67%), power Doppler tenosynovitis (PDTS - 78% vs 49%) and erosions (20% vs 0) (p < 0.01). Figure 1 illustrates the pre-treatment proportions and change in group proportions at each timepoint, revealing an early shift of AC to AD (36% by week 12) or RC (22% by week 12) but persistence of those in AD from baseline at subsequent timepoints (64% at week 12). Baseline characteristics associated with each group compared to the comparator AC group (at weeks 12, 24 and 48) are reported in Table 1. For AD versus AC these were lower CRP at week 12 and female sex at week 24. For RC versus AC these were lower CRP and allocation to ETN+MTX at week 12, allocation to ETN+MTX and presence of PDTS at week 24 and younger age at week 48. For RD versus AC these were presence of PDTS at week 24 and male sex at week 48.

Table 1.

Baseline characteristics associated with longitudinal discordance vs concordance. AC is the comparator group. Results in posterior estimate with 95% credible intervals

Week 12Week 24Week 48AD vs ACFemale0.53 (-0.44 to 1.48)1.52 (0.51 to 2.59)0.17(-0.91 to 1.25)CRP-0.05 (-0.1 to -0.01)-0.01 (-0.04 to 0.05)0.01(-0.02 to 0.02)RC vs ACAge at diagnosis-0.04(-0.09 to 0.01)-0.02(-0.06 to 0.03)-0.08(-0.13 to -0.03)CRP-0.05 (-0.10 to -0.01)0.001(-0.04 to 0.03)0.01(-0.02 to 0.04)ETN+MTX1.57, (0.57 to 2.64)1.26, (0.29 to 2.33)0.91(-0.02 to 1.85)PDTS0.58 (-0.5 to 1.68)1.23(0.2 to 2.29)0.8 (-0.2 to 1.83)RD vs ACFemale0.23 (-1.26 to 1.72)0.9 (-0.41 to 2.26)-1.59(-2.9 to -0.35)PDTS1.00 (-0.55 to 2.69)1.79 (0.44 to 3.33)0.95(-0.29 to 2.27)

Conclusion

DAS28ESR and PDUS discordance and concordance have distinct clinical and imaging phenotypes at presentation. Baseline active concordance and discordance respond differently to treatment –a sizeable proportion of former transition into active discordance early on and the latter persist in the face of effective treatment. Understanding the basis for these phenotypes is essential to facilitate optimal aggressive treatment and/or alternative management strategies.

References

[1]Emery P, Horton S, Dumitru RB, et al. Pragmatic randomised controlled trial of very early etanercept and MTX versus MTX with delayed etanercept in RA: The VEDERA trial. Ann Rheum Dis. 2020;79(4):464–71.

Disclosure of Interests

None declared.

OP0168 DEVELOPMENT OF AN ULTRASOUND SCORING SYSTEM FOR CPPD EXTENT: RESULTS FROM A DELPHI PROCESS AND WEB-RELIABILITY EXERCISE BY THE OMERACT US WORKING GROUP

Background

Ultrasound (US) has proven to be an excellent imaging technique for detecting calcium pyrophosphate (CPP) deposition disease (CPPD); it is also widely available and inexpensive and can be performed during the clinic visit making it the preferred imaging modality for many rheumatologists. However, no validated grading systems have yet been developed allowing for a quantification of the extent of crystal deposition in CPPD.

Objectives

The aim of this study was to develop a scoring system for the quantification of CPP deposition at a patient level according to the OMERACT framework.

Methods

As part of the OMERACT methodology, we performed a systematic literature review (SLR) and meta-analysis aimed to estimate the prevalence of CPP deposition in peripheral joints by imaging, in order to identify relevant joints for CPPD monitoring. A preliminary survey was also circulated among the members of the OMERACT US – CPPD working group to collect their own suggestions according to their personal experience. Subsequently, a Delphi survey was prepared and circulated between members of the group, including statements that reflected both the results of the SLR and of the preliminary survey. In total, 32 statements were generated regarding the type of scoring for single structures, the sites to be included, the final scoring at patient level, and the scanning technique. Participants were asked to reply on a 5-point Likert scale (1, strongly disagree to 5, strongly agree) and agreement was achieved when 4 and 5 grades reached 75% or more of concordance. In case of disagreement, new statements were proposed according to the members’ suggestions and circulated for voting in a subsequent round. After agreement of a scoring system, the validation process began. Two rounds of a web-based exercise on static images were conducted on 120 images representing equally all sites under investigation and all degrees of crystal deposition, to assess the intra- and inter-reader reliability of the new scoring system. Representative images of the scoring system were visible throughout the entire exercise in order to facilitate the scoring of the lesions.

Results

Three Delphi rounds were needed to reach agreement on all items. 32/41 members of the OMERACT US-CPPD working group replied in the first round, 26/32 in the second, and 25/26 in the third round. Twenty statements were approved in the first round, 3 in the second, and 3 in the third round. Only the knees (menisci and hyaline cartilage) and the triangular fibrocartilage of the wrist were included in the final score, using a four-grade system (0-3). It was decided that each anatomical structure should be scored separately and then also summed in order to define the joint score. The sum of the assessed joints was the total score at patient level. The final scoring system with the definitions and the relative technical notes is represented in Figure 1. 33/41 members participated to the reliability exercise. The inter-reader reliability of the scoring was substantial (kappa of 0.72), and the intra-reader reliability was almost perfect (kappa of 0.82).

Conclusion

This is the first study for developing a scoring system for the extent of CPP crystal deposition in patients with CPPD. The scoring system demonstrated to be reliable in static images. The next step of the validation process is to assess the reliability of the scoring system in a patient-based exercise. This study represents a fundamental step in the OMERACT process of validating US as an outcome measure instrument, and above proposed scoring system will hopefully provide a useful tool for clinical practice and research.

Disclosure of Interests

None declared

POS0464 IS IT POSSIBLE TO IDENTIFY INDIVIDUALS AT IMMINENT-RISK OF SUB-CLINICAL JOINT INVOLVEMENT?

Background:

In anti-CCP antibody (Ab) positive at-risk individuals with MSK symptoms but without clinical synovitis, the detection of ultrasound (US) subclinical inflammation is associated with an increased risk of progression to inflammatory arthritis (IA) 1. Studies suggest that in these at-risk individuals, MSK symptoms develop before subclinical joint inflammation occurs on US. As such, anti-CCP Ab positive individuals with MSK symptoms in the absence of clinical or sub-clinical inflammation may be at the critical time-point for preventive treatments, before joint inflammation occurs and eventually becomes established (i.e., before the ‘second-hit’ in RA pathogenesis); however, identifying these individuals is challenging.

Objectives:

To identify, in second generation anti-CCP Ab (CCP2+) at-risk individuals with MSK symptoms, but without clinical or sub-clinical synovitis, predictors of US sub-clinical synovitis.

Methods:

In 186 CCP2+ at-risk individuals with normal baseline US scan (i.e., no synovitis or bone erosions), and a complete dataset, US data were analyzed at 6, 12 months, then annually until occurrence of IA. US synovitis was identified according to the EULAR/OMERACT definitions2. Relevant demographic (age and gender), clinical [early morning stiffness (EMS), tenderness in the small joints of the hands] and serological [anti-CCP2 Ab level, third generation anti-CCP Ab (CCP3) and rheumatoid factor (RF)] data were collected at baseline. Regression analyses, Kaplan-Meier analysis and Log-Rank test were performed.

Results:

US synovitis was detected in ≥1 longitudinal US scan in 69/186 (37.1%) at-risk individuals (median time to first developing US synovitis: 53 weeks, IQR 27.0-105.8; median number of joints with US synovitis: 2.0, IQR 1.0-2.0). As shown in Table 1, only anti-CCP3 Ab were significantly associated with development of US sub-clinical synovitis in the multi-variable analysis while borderline results were observed with age.

Table 1.

Regression analyses for the development of US synovitis.

Univariable analysisMultivariableanalysisOR (95% CI)p-valueOR (95% CI)p-valueGender (male)1.02 (0.52-2.02)0.95//Age1.03 (1.01-1.06)<0.011.03 (1.00-1.06)0.03Tenderness in the hands0.86 (0.46-1.61)0.64//EMS1.60 (0.87-2.95)0.13//Anti-CCP2 Ab (high titre)2.79 (1.37-5.67)<0.011.20 (0.50-2.89)0.69Anti-CCP3+4.44 (2.28-8.66)<0.013.30 (1.39-7.89)<0.01RF+2.96 (0.46-1.61)0.011.45 (0.68-3.11)0.33

CCP2+ individuals with positive anti-CCP3 Ab show a significantly reduced sub-clinical synovitis-free survival rate compared with individuals with negative anti-CCP3 Ab (Figure 1). At 1- and 2-year follow-up, respectively 23.3% and 38.3% of individuals with dual CCP2/CCP3 positivity developed sub-clinical synovitis on longitudinal scans, compared with 8.4% and 13.3% of CCP2+ individuals with negative anti-CCP3 Ab (p=0.01) (Figure 1a).

Similar results were observed in the subgroup of high level CCP2+ individuals. At 1- and 2-year follow-up, respectively 24.5% and 39.4% of high level CPP2/anti-CCP3+, but only 6.1% and 15.2% of CCP2+ individuals with negative anti-CCP3 developed sub-clinical synovitis on longitudinal scans (p<0.01) (Figure 1b).

Figure 1.

Kaplan-Meier analysis shows US sub-clinical synovitis free survival time in CCP2+ at-risk individuals.

Conclusion:

In anti-CCP2+ at-risk individuals with MSK symptoms, anti-CCP3 antibodies improve prediction of imminent development of subclinical joint inflammation. This may represent the critical time-point for interventions to prevent the onset of joint disease. This is also a unique population for investigating the drivers of joint involvement in the development of RA.

References:

[1]Duquenne L, et al. The Role of Ultrasound Across the Inflammatory Arthritis Continuum: Focus on “At-Risk” Individuals. 2020.

[2]D’Agostino MA, et al. Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce — Part 1: definition and development of a standardised, consensus-based scoring system. 2017.

Disclosure of Interests:

Andrea Di Matteo Grant/research support from: This study was conducted while Andrea Di Matteo was an ARTICULUM Fellow., Kulveer Mankia Speakers bureau: KM reports personal fees from Abbvie, UCB and Eli Lilly (all <$10.000), outside the submitted work., Grant/research support from: Research grants from BMS, Eli Lilly (all <$10.000), Laurence Duquenne: None declared, Edoardo Cipolletta: None declared, Jacqueline Nam: None declared, Leticia Garcia-Montoya: None declared, Richard Wakefield Speakers bureau: RJW has received honoraria from Abbvie, Novartis and GE for ultrasound related educational activities (all <$10.000)., Michael Mahler Employee of: MM is employee of Inova Diagnostics, commercializing CCP3, Paul Emery Speakers bureau: PE reports consultant fees from BMS, AbbVie, Gilead, Galapagos, Lilly, MSD, Pfizer, Novartis, Roche, and Samsung outside the submitted work (all <$10.000)., Grant/research support from: He also reports research grants from UCB, AbbVie, Lilly, Novartis, BMS, Pfizer, MSD and Roche, outside the submitted work. PE is National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) director and BRC funds supported this work. Leticia Garcia-Montoya and Laurence Duquenne are NIHR BRC fellows.

SAT0413 DACTYLITIS IS ASSOCIATED WITH DISEASE SEVERITY AND ULTRASOUND DEFINED EROSIVE DAMAGE IN VERY EARLY, DMARD NAÏVE PSORIATIC ARTHRITIS

Background:

Dactylitis is a hallmark feature of Psoriatic arthritis (PsA) and Spondyloarthritis (SpA) defined as a uniform swelling of a digit (“sausage digit”). Dactylitis is associated with radiographic damage in chronic PsA. However, there are a paucity of data on the significance of dactylitis and its potential impact in disease burden in early PsA.

Objectives:

To characterize a very early DMARD naïve PsA cohort based on clinical presence or absence of dactylitis at disease onset.

Methods:

PsA subjects fulfilling the CASPAR classification criteria, were recruited into a prospective observational cohort, the Leeds Spondyloarthropathy Register for Research and Observation (SpARRO) after providing informed written consent. Clinical data including tender (TJC) and swollen joint counts (SJC) were independently assessed. Dactylitis was recorded per digit (finger or toe) as tender (hot) or non-tender (cold). Differences in baseline characteristics were evaluated using percentages to describe categorical variables and means and standard deviations for continuous variables, p value of the mean/proportion difference was calculated. Ultrasound (US) examination was conducted by trained ultra-sonographers blinded to clinical details. Bone erosions were defined on US if intra-articular discontinuity was present in two perpendicular planes at any of 46 joints: wrists, MCP1-5, PIP2-5, DIP2-5, MTP1-5, knees, ankles, subtalar, talonavicular.

Results:

A total of 177 PsA patients were recruited. Dactylitis was seen in nearly half the cohort [n=83 (47%)]. Patients with dactylitis had significantly more early morning stiffness, higher TJC and SJC, compared with non-dactylitis (Table 1). A total of 211 digits with dactylitis were recorded in 83 patients. Dactylitis of multiple digits was seen in 47/83 (57%) patients whilst a single dactylitic digit occurred in 36/83 (43%). Foot involvement was more prevalent (141/211, 67%) than hands (70/211, 33%). “Hot” or tender dactylitis was more frequently detected (153/211, 72.5%) than “cold” or non-tender dactylitis (58/211, 27.5%). The most prevalent sites for hot dactylitis were toes 2-4thand fingers 2-3rd.

Table 1.VariableNo Dactylitis (n=94)Dactylitis (n=83)P valueAge, mean (SD) years44.4 (12.8)43.7 (13.2)>0.05Male38 (40.4%)42 (50.6%)>0.05Disease duration, median (IQR) weeks4.7 (0.0-11.4)5.2 (1-22.4)>0.05Early Morning stiffness, mean (SD) mins82.8 (145.4)170.5 (230.2)0.0025*TJC (78), mean (SD)8.3 (10.9)13.7 (14.0)0.004*SJC (76), mean (SD)2.2 (3.2)8.4 (8.0)<0.001*Psoriasis94/94 (100.0%)76/83 (91.6%)0.004*PASI, mean (SD)3.6 (4.0)3.0 (4.1)>0.05Nail Dystrophy51/94 (54.3%)41/83 (49.4%)>0.05mNAPSI, mean (SD)4.9 (7.1)7.5 (14.0)>0.05MASES, mean (SD)1.6 (2.9)1.5 (2.4)>0.05BMI, mean (SD)29.1 (6.4)28.6 (5.6)>0.05Smoker19.0 (20.2%)9.0 (10.8%)>0.05Elevated CRP (>10 mg/L)24 (25.5%)36 (43.4%)>0.05PsAQoL, mean (SD)6.2 (6.6)6.2 (6.1)>0.05HAQ, mean (SD)0.79 (0.71)0.84 (0.65)>0.05US Erosions (n=154)12/83 (14.4%)21/71 (29.5%)0.023*

US defined erosions were significantly more prevalent in the dactylitis group: 34 erosions in 21/71 patients (29.5%) versus 16 erosions in 12/83 (14.4%) patients in non-dactylitis. Sites prone to erosive damage in both groups were the wrists, MCP1,2 and MTP4,5. The right MCP2 (n=6) and MTP5 (n=6) were most commonly eroded in the dactylitis group, but erosions corresponding at the dactylitic digit level were overall low.

Conclusion:

This study identifies a more severe phenotype in very early DMARD naïve PsA presenting with dactylitis with higher prevalence of ultrasound erosions. Longitudinal follow up will determine whether dactylitis represents a poor prognostic factor in very early PsA, which may be a useful discriminator for risk stratification in future PsA management recommendations.

Disclosure of Interests:

Sayam Dubash: None declared, Oras Alabas: None declared, Xabier Michelena: None declared, Gabriele De Marco: None declared, Leticia Garcia-Montoya: None declared, Richard Wakefield Speakers bureau: Novartis, Janssen, GE, Ai Lyn Tan: None declared, Philip Helliwell: None declared, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Dennis McGonagle Grant/research support from: Janssen Research & Development, LLC, Helena Marzo-Ortega Grant/research support from: Janssen, Novartis, Consultant of: Abbvie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, UCB, Speakers bureau: Abbvie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, Takeda, UCB

AB1174 TRACKING THE EFFECTS ON A CLINICAL SERVICE OF INTRODUCING ULTRASOUND FOR DIAGNOSIS OF GIANT CELL ARTERITIS: DESIGN OF A SERVICE EVALUATION USING LEAN METHODOLOGY

Background:

In our large, multi-site hospital, patients with suspected GCA are started promptly on high-dose prednisolone but until 2019, patients waited for temporal artery biopsy (TAB) until the GCA diagnosis could be confirmed (“GCA”) or refuted (“not-GCA”). Reports of the impact of introducing temporal and axillary artery ultrasound (TAUS) have mainly come from smaller hospitals. Agreement between TAUS and TAB has been reported by others with a Cohen’s kappa of 0.35 [1] and 0.40 [2]. We used Lean methodology to identify metrics across 5 key domains: delivery, quality, service, morale and cost.

Objectives:

To design metrics for a service evaluation to measure impact of introducing TAUS, and to test their feasibility of measurement within routine care.

Methods:

Our primary driver was time from presenting to our service to diagnostic confirmation (lead time). Pathway mapping, value stream mapping and a driver diagram identified key ideas for improvement.

We chose to measure: Delivery (mean lead time for each month), Quality (proportion of patients with GCA and positive TAB/TAUS; total (cumulative) prednisolone dose in patients with not-GCA, Service (patient feedback), Morale (staff feedback) and Cost (number of patients; cost of tests per patient; overall costs). We plotted these by month on run charts and defined a significant shift as 6 consecutive monthly values below baseline median. Cohen’s kappa was calculated using GraphPad QuickCalcs.

Results:

Routine TAUS for suspected GCA was introduced from January 2019, alongside a multidisciplinary team monthly meeting. TAUS was done a median of 2.5 days from referral. Agreement between TAB and TAUS results was good (Table 1). The run chart showed a significant shift in our Delivery (median lead time fell from 28.7 days to 21 days after introduction of ultrasound) and both Quality metrics (proportion of GCA with positive TAB/TAUS increased from 29% to 69%; total prednisolone dose for not-GCA fell from 1.335g to 0.846g).

Table 1.

Concordance between temporal and axillary artery ultrasound (TAUS) and temporal artery biopsy (TAB) in scans performed through 2019. Cohen’s weighted kappa 0.59 (including equivocal results as separate category).

TAUS positiveTAUS negativeTAUS equivocalTAB positive1411TAB negative5275TAB equivocal030

Within Costs, average per-patient costs of TAB/TAUS declined from £1004/patient to £792/patient, but total referrals for TAB/TAUS increased from 6/month to 10/month, increasing overall costs. Staff and patient feedback (Service, Morale) revealed that further improvements to the care pathway were needed to manage the additional complexity.

Conclusion:

Lean methodology identified multiple metrics for evaluating the impact of TAUS on our service. Introducing TAUS improved Delivery and Quality, but measuring Costs, Morale and Service helped identify unintended consequences. Concordance between TAUS and TAB was good. We plan to continue to improve and monitor the care pathway based on our multi-stakeholder feedback.

References:

[1]Luqmani et al., HTA 2016

[2]Mukhtyar et al., Clin Rheum 2019

Disclosure of Interests:

Sarah Mackie Grant/research support from: Roche (attendance of EULAR 2019; co-applicant on research grant), Consultant of: Sanofi, Roche/Chugai (monies paid to my institution not to me), Andrew Barr: None declared, Alison Cracknell: None declared, Shannon Farrell: None declared, Jimmy Parvin: None declared, Ajay Patil: None declared, Ian Simmons: None declared, Kate Smith Grant/research support from: Medical education grants from Sanofi and Biogen, Speakers bureau: Novartis, Andrea Sweeting: None declared, Max Troxler: None declared, Tara Webster: None declared, Richard Wakefield Speakers bureau: Novartis, Janssen, GE

FRI0557 IN INDIVIDUALS AT-RISK OF RHEUMATOID ARTHRITIS, ULTRASOUND BONE EROSIONS AT THE V METATARSOPHALANGEAL JOINTS ARE THE MOST PREDICTIVE FOR THE DEVELOPMENT OF CLINICAL ARTHRITIS

Background:

While the central role of bone erosions in the pathogenesis and diagnosis of patients with rheumatoid arthritis (RA) is widely recognized, their prevalence, pattern, and relationship with subclinical synovitis in individuals at-risk of RA (positive autoantibodies without clinical arthritis) is not well understood.

Objectives:

To investigate, in individuals at-risk of RA, the prevalence and distribution of ultrasound (US) bone erosions, their correlation with subclinical synovitis at joint level, and their association with the development of inflammatory arthritis (IA).

Methods:

Baseline US scans of 2ndgeneration anti-cyclic citrullinated peptide (CCP) positive at-risk subjects with musculoskeletal symptoms (without clinical arthritis) taking part in the Leeds CCP study were analyzed. The presence of bone erosions was evaluated in the classic sites for RA damage: the II and V metacarpophalangeal (MCP) joints, and the V metatarsophalangeal (MTP) joints1. US synovitis was defined as synovial hypertrophy (SH) ≥2 or SH ≥1 + power Doppler signal ≥12. Only subjects with ≥1 follow-up visit were included in the progression analysis (n=400). Progression to IA was defined as the development of clinical synovitis in ≥1 one joint.

Results:

US bone erosions: prevalence, distribution, and association with subclinical synovitis

A total of 2514 joints, in 419 subjects were evaluated.

Bone erosions were found in ≥1 joint in 41/419 subjects (9.8%), in 55/2514 joints (2.2%). The prevalence of bone erosions was significantly higher in the V MTP than in the MCP joints (p<0.01). They were detected in 42 V MTP (31 subjects; 7.4%), in 10 II MCP (10 subjects; 2.4%), and in 3 V MCP (3 subjects; 0.7%) joints. US synovitis was detected in 22/55 joints (40%) with bone erosions, in 17/41 subjects (42%). It was found in 48.6% of the V MTP, in 20% of the II MCP and in none of the V MCP joints with bone erosions. A significant correlation between bone erosions and synovitis in the same joint was detected (Cramer’s V=0.22, p<0.01).

Seven out of the 55 joints (12.7%) with bone erosions were tender on physical examination: 14.3% of the V MTP, 10% of the II MCP, and none of the V MCP joints.

US bone erosions: predicting development of IA

A total of 122 subjects (30.5%) developed IA (median follow-up: 301 days, IQR 112-721). The hazard ratios of the US findings for the development of IA (adjusted for age, sex, smoking, anti-CCP and rheumatoid factor titer) are reported in Table 1.

Table 1.EverAt 1 yearAt 3 yearsHR (95%CI)P valueHR (95%CI)P valueHR (95%CI)P valuePresence of bone erosion in ≥1 joint (any joint)3.98(1.82-8.7)<0.013.57(1.7-7.5)<0.013.48(1.63-7.4)<0.01- in the II MCP joints2.4(0.52-11.08)0.261.07(0.2-5.76)0.941.67(0.38-7.04)0.5- in the V MCP joints1.37(0.06-31)0.850(N/A)10(N/A)1- in the V MTP joints4.79(1.97-11.63)<0.015.23(2.32-11.8)<0.015.43(2.28-12.92)<0.01Presence of bone erosion and synovitis in the same joint (any joint)3.9(1.19-12.77)0.026.03(2.07-17.55)<0.013.91(1.29-11.85)0.02Presence of bone erosion and synovitis in the same V MTP joint5.08(1.37-18.9)0.027.03(2.28-21.71)<0.014.89(1.48-16.19)<0.01Presence of bone erosion in >1 joint (any joint)10.63(1.87-60.42)<0.015.68(1.66-19.5)<0.017.26(1.67-31.66)<0.01

IA free survival rates are showed in Figures 1 and 2.

Figure 1.Figure 2.

Conclusion:

The feet appear to be an early site for damage in individuals at-risk of RA. US bone erosions were mainly detected in asymptomatic joints, but frequently in association with subclinical synovitis. In individuals at-risk of RA, bone erosions in the V MTP joints are more predictive than in the hands (II and V MCP joints) for the development of IA.

References:

[1] Zayat AS, et al. Ann Rheum Dis. 2015;

[2] D’Agostino, et al. RMD Open. 2017;

Disclosure of Interests:

Andrea Di Matteo Grant/research support from: the publication was conducted while Dr. Di Matteo was an ARTICULUM fellow, Kulveer Mankia: None declared, Laurence Duquenne: None declared, Edoardo Cipolletta: None declared, Richard Wakefield Speakers bureau: Novartis, Janssen, GE, Jacqueline Nam: None declared, Leticia Garcia-Montoya: None declared, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor)

THU0619-HPR PREVALENCE OF DISTAL INTERPHALANGEAL JOINT ULTRASONOGRAPHY FEATURES IN PSORIATIC ARTHRITIS, SKIN PSORIASIS, OSTEOARTHRITIS AND HEALTHY INDIVIDUALS: A CROSS-SECTIONAL STUDY

Background:

Distal interphalangeal (DIP) joint involvement is a feature of both psoriatic arthritis (PsA) and hand osteoarthritis (OA), and nail-changes are features seen both in PsA and nail psoriasis patients without joint involvement (PsO). In both PsA and OA, ultrasonography (US) is used to quantify DIP joint inflammation.

Objectives:

To explore disease-specific US-detected characteristics in the DIP-joints and extensor tendon entheses in patients with DIP-joint OA, PsA, PsO with nail involvement, and healthy controls (HC).

Methods:

In PsA, PsO, OA and HC US examination of DIP joints 2-5 and the extensor tendon were performed. The US images were scored for DIP joint grey-scale synovitis, DIP joint Doppler, osteophytes and erosions (grade 0-3) and presence/absence of enthesitis and peritendonitis of the extensor tendon according to OMERACT standards. Prevalences were calculated on all included fingers (i.e. four fingers per participant), and differences in prevalences were tested using Chi-square statistics.

Results:

Fifty PsA patients (44% females; mean age: 55y), 13 PsO patients (38% females; mean age 54y), 12 OA patients (100% females, mean age 71y), and 29 HC (52% females, mean age 48y) participated. The prevalences across the diagnosis groups are shown in figure 1, and the distribution of US outcomes was significantly different (highest Chi-square P-value: 0.0127). The PsA group had the largest prevalence of extensor tendon enthesitis (45.5%), peritendonitis (15%), and DIP joint erosions (11%), but also exhibited a considerable prevalence of osteophytes (46%). In the PsO group, the most marked findings were synovitis (33%) and enthesitis (35%). The OA group had the largest prevalence of DIP joint synovitis (67%) and osteophytes (88%) but also 25% prevalence of enthesitis. 24% of the HC group had a grade 1 synovitis.

Conclusion:

This cross-sectional study found significant patterns of US findings distributed dependent on the underlying condition. PsA patients were mainly differentiated by the presence of extensor tendon enthesitis and peritendonitis. A high prevalence of enthesitis and synovitis was seen in patients with DIP joint OA. The high prevalence of enthesitis in PsO is consistent with a preclinical phase of PsA in this group.

Disclosure of Interests:

Jørgen Guldberg-Møller Speakers bureau: Novartis, Ely Lilly, AbbVie, BK Ultrasound, Marius Henriksen: None declared, Mikael Boesen Speakers bureau: Image Analysis Group, AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Lene Dreyer: None declared, Karen Ellegaard: None declared, Marie Skougaard: None declared, Christine Ballegaard: None declared, Ai Lyn Tan: None declared, Richard Wakefield Speakers bureau: Novartis, Janssen, GE, Lars Erik Kristensen Consultant of: UCB Pharma (Advisory Board), Sannofi (Advisory Board), Abbvie (Advisory Board), Biogen (Advisory Board), Speakers bureau: AbbVie, Amgen, Biogen, Bristol-Myers Squibb,Celgene, Eli Lilly, Gilead, Forward Pharma, Janssen Pharmaceuticals, MSD, Novartis, Pfizer, and UCB Pharma

SAT0401 SWOLLEN JOINTS ARE ASSOCIATED WITH ULTRASOUND POWER DOPPLER SYNOVITIS, WHEREAS TENDER JOINTS IN THE ABSENCE OF SWELLING ARE NOT: AN ANALYSIS OF AGREEMENT AND CORRELATION IN VERY EARLY DMARD NAÏVE PSORIATIC ARTHRITIS

Background:

Ultrasound (US) is an imaging adjunct to clinical joint examination adding sensitivity and objectivity to the assessment of inflammation. Previous studies in PsA have shown disparity between ultrasound and clinical findings with significant subclinical joint inflammation. A clinical challenge in PsA is to interpret tender joints (TJ) that are not swollen (SJ). As US is not widely used, alignment of clinical with US assessment is needed to determine its future role.

Objectives:

To determine how joint clinical examination relates to US findings in very early DMARD naïve PsA.

Methods:

Newly diagnosed DMARD naïve PsA patients, fulfilling CASPAR criteria, were recruited into the Leeds Spondyloarthropathy Register for Research and Observation (SpARRO), a prospective observational cohort study. US examination of 48 joints per patient was conducted by trained ultra-sonographers, blinded to clinical details with semi-quantitative scoring (0-3) for gray scale (GS) and power Doppler (PD). TJ and SJ counts were independently recorded. Cross-sectional baseline analysis was performed. The prevalence-adjusted and bias-adjusted kappa (PABAK) was calculated to determine agreements between clinical and US parameters. Spearman’s rank correlation coefficient was calculated to identify permutations of TJ/SJ correlating with GS ≥2, PD≥1 or both.

Results:

A total 5927 joints were scanned in 155 PsA patients. The mean age was 44.4 years, (SD 12.8), median disease duration 5.1 weeks (0.4-13.1); median TJC=7 (3-14) and SJC=2 (1-7). Oligoarthritis was present in 63.9% (99/155). US GS≥2 was frequently detected in the feet at MTPs1-4 (37.4- 53.6 %) and wrists (26.5- 33.6%). PD was most prevalent at wrists (17.5%) and MTP1 (12.6%) but observed less in other joints. Erosions were less frequent, the commonest site being MTP5 (17/310, 5.4%).

Overall, SJ demonstrated high agreement (p<0.001) with US synovitis (GS ≥2 and/or PD ≥1). High agreement was equivalent between combined GS ≥2 and PD ≥1 compared with PD ≥1 alone (p<0.001) indicating it was predominantly driven by PD. Agreement with TJ and US was consistently lower yet still significant (p<0.001). Combinations of TJ/SJ were explored with US synovitis (table 1). Correlation was significant for T+ S+ and PD≥1 at wrists, MCP1-5, PIP2-5, MCP3-4 (p<0.001); DIP2 (p<0.05), knees and ankles (p<0.01) but weaker correlation in MTP3,4. In contrast, poor correlation was observed in the T+ S- group for most joints.

Table 1.

Agreement between TJ or SJ with GS≥2 & PD ≥1 and correlations for tender with/ without swollen combinations for right sided hand/feet joints.

TenderSwollenT+ S-T+ S+Joint (Right)A (%)PABAKA (%)PABAKrrWrist75.50.51*89.10.78*-0.090.35*MCP184.10.68*87.50.75*0.090.44*MCP277.70.55*83.10.66*0.080.35*MCP379.10.58*84.50.69*0.0050.50*MCP478.40.57*86.40.72*0.070.22†MCP587.80.76*95.60.91*-0.030.49*MTP169.80.40*83.90.68*-0.03-MTP279.10.58*90.50.81*0.060.11MTP377.00.54*88.50.77*0.050.22‡MTP477.70.55*87.20.74*-0.0020.23‡MTP579.90.60*89.90.80*0.150.09

T+= tender, S+ =swollen, S- = not swollen, A=agreement (%), r =coefficient, † p<0.05, ‡ p<0.01, *p<0.001.

Conclusion:

Swollen joints demonstrate higher agreement with US synovitis (PD≥1 alone or GS ≥2 & PD ≥1 combined) than tender joints in early PsA. In addition, joints that are tender but not swollen have poor correlation with US synovitis at the individual joint level indicating that swelling is a better clinical discriminator of active synovitis, and factors other than synovial inflammation may drive tenderness in very early, DMARD naïve PsA. These results suggest re-appraisal of clinical joint counts is needed to refine treatment decision making in early PsA.

Disclosure of Interests:

Sayam Dubash: None declared, Oras Alabas: None declared, Xabier Michelena: None declared, Leticia Garcia-Montoya: None declared, Gabriele De Marco: None declared, Mira Merashli: None declared, Richard Wakefield Speakers bureau: Novartis, Janssen, GE, Philip Helliwell: None declared, Dennis McGonagle Grant/research support from: Janssen Research & Development, LLC, Ai Lyn Tan: None declared, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor), Helena Marzo-Ortega Grant/research support from: Janssen, Novartis, Consultant of: Abbvie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, UCB, Speakers bureau: Abbvie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, Takeda, UCB

Optimising ultrasonography in rheumatology

Ultrasonography is an imaging modality that has been utilised in clinical medicine since the 1950s. However, application to joints and rheumatic disease was delayed until appropriate advances in technology made it feasible. Since the 1990s, rheumatologists have embraced ultrasonography as a useful clinical tool and it has increasingly been applied in routine practice. Initial criticism correctly focused on a lack of validity data, recognition that this modality is highly user-dependent and that reliability was not established. In response, the rheumatological community identified relevant pathologies to study, starting with synovitis in rheumatoid arthritis, and set about defining the ultrasound abnormalities, followed by demonstrating the validity, reproducibility and responsiveness of these measures. Much work is now ongoing in the areas of enthesitis, gout and osteoarthritis. Additionally, the evidence base for ultrasonography in clinical practice is being investigated, in order to understand its appropriate place. Given the sensitivity of ultrasonography over clinical examination for detection of inflammation, this work will focus on its role in optimising diagnosis, directing therapy through accurate assessment of disease activity and understanding the optimal selection of joints for feasible disease monitoring. This review summarises the work undertaken to date, ongoing work and future challenges of optimising the role of ultrasonography in rheumatology.

EFSUMB minimum training requirements for rheumatologists performing musculoskeletal ultrasound

In order to optimize and standardize musculoskeletal ultrasonography education for rheumatologists, there is a need for competency assessments addressing the required training and practical and theoretical skills. This paper describes how these competency assessments for rheumatologists were developed and what they contain.

Estimating sediment and caesium-137 fluxes in the Ribble Estuary through time-series airborne remote sensing

High spatial and temporal resolution airborne imagery were acquired for the Ribble Estuary, North West England in 1997 and 2003, to assess the application of time-series airborne remote sensing to quantify total suspended sediment and radionuclide fluxes during a flood and ebb tide sequence. Concomitant measurements of suspended particulate matter (SPM) and water column turbidity were obtained during the time-series image acquisition for the flood and ebb tide sequence on the 17th July 2003 to verify the assumption of a vertically well mixed estuary and thus justifying the vertical extrapolation of spatially integrated estimate of surface SPM. The ¹³⁷Cs activity concentrations were calculated from a relatively stable relationship between SPM and ¹³⁷Cs for the Ribble Estuary. Total estuary wide budgets of sediment and ¹³⁷Cs were obtained by combining the image-derived estimates of surface SPM and ¹³⁷Cs with estimates of water volume from a two-dimensional hydrodynamic model (VERSE) developed for the Ribble Estuary. These indicate that around 10,000 tons of sediment and 2.72 GBq of ¹³⁷Cs were deposited over the tidal sequence monitored in July 2003. This compared favourably with bed height elevation change estimated from field work. An uncertainty analysis on the total sediment and ¹³⁷Cs flux yielded a total budget of the order of 40% on the final estimate. The results represent a novel approach to providing a spatially integrated estimate of the total net sediment and radionuclide flux in an intertidal environment over a flood and ebb tide sequence.

Clinical and ultrasonographic predictors of joint replacement for knee osteoarthritis: results from a large, 3-year, prospective EULAR study

OBJECTIVES

To determine clinical and ultrasonographic predictors of joint replacement surgery across Europe in primary osteoarthritis (OA) of the knee.

METHODS

This was a 3-year prospective study of a painful OA knee cohort (from a EULAR-sponsored, multicentre study). All subjects had clinical evaluation, radiographs and ultrasonography (US) at study entry. The rate of knee replacement surgery over the 3-year follow-up period was determined using Kaplan-Meier survival data analyses. Predictive factors for joint replacement were identified by univariate log-rank test then multivariate analysis using a Cox proportional-hazards regression model. Potential baseline predictors included demographic, clinical, radiographic and US features.

RESULTS

Of the 600 original patients, 531 (88.5%), mean age 67+/-10 years, mean disease duration 6.1+/-6.9 years, had follow-up data and were analysed. During follow-up (median 3 years; range 0-4 years), knee replacement was done or required for 94 patients (estimated event rate of 17.7%). In the multivariate analysis, predictors of joint replacement were as follows: Kellgren and Lawrence radiographic grade (grade > or =III vs <III, hazards ratio (HR) = 4.08 (95% CI 2.34 to 7.12), p<0.0001); ultrasonographic knee effusion (> or =4 mm vs <4 mm) (HR = 2.63 (95% CI 1.70 to 4.06), p<0.0001); knee pain intensity on a 0-100 mm visual analogue scale (> or =60 vs <60) (HR = 1.81 (95% CI 1.15 to 2.83), p=0.01) and disease duration (> or =5 years vs <5 years) (HR=1.63 (95% CI 1.08 to 2.47), p=0.02). Clinically detected effusion and US synovitis were not associated with joint replacement in the univariate analysis.

CONCLUSION

Longitudinal evaluation of this OA cohort demonstrated significant progression to joint replacement. In addition to severity of radiographic damage and pain, US-detected effusion was a predictor of subsequent joint replacement.

EULAR report on the use of ultrasonography in painful knee osteoarthritis. Part 2: exploring decision rules for clinical utility

BACKGROUND

Synovial inflammation (as defined by hypertrophy and effusion) is common in osteoarthritis (OA) and may be important in both pain and structural progression.

OBJECTIVE

To determine if decision rules can be devised from clinical findings and ultrasonography (US) to allow recognition of synovial inflammation in patients with painful knee OA.

METHODS

A EULAR-ESCISIT cross sectional, multicentre study enrolled subjects with painful OA knee who had clinical, radiographic, and US evaluations. A classification and regression tree (CART) analysis was performed to find combinations of predictor variables that would provide high sensitivity and specificity for clinically detecting synovitis and effusion in individual subjects. A range of definitions for the two key US variables, synovitis and effusion (using different combinations of synovial thickness, depth, and appearance), were also included in exploratory analyses.

RESULTS

600 patients with knee OA were included in the analysis. For both knee synovitis and joint effusion, the sensitivity and specificity were poor, yielding unsatisfactory likelihood ratios (75% sensitivity, 45% specificity, and positive LR of 1.36 for knee synovitis; 71.6% sensitivity, 43.2% specificity, and positive LR of 1.26 for joint effusion). The exploratory analyses did not improve the sensitivity and specificity (demonstrating positive LRs of between 1.26 and 1.57).

CONCLUSION

Although it is possible to determine clinical and radiological predictors of OA inflammation in populations, CART analysis could not be used to devise useful clinical decision rules for an individual subject. Thus sensitive imaging techniques such as US remain the most useful tool for demonstrating synovial inflammation of the knee at the individual level.

EULAR report on the use of ultrasonography in painful knee osteoarthritis. Part 1: prevalence of inflammation in osteoarthritis

OBJECTIVES

To assess the prevalence of inflammation in subjects with chronic painful knee osteoarthritis (OA), as determined by the presence of synovitis or joint effusion at ultrasonography (US); and to evaluate the correlation between synovitis, effusion, and clinical parameters.

METHODS

A cross sectional, multicentre, European study was conducted under the umbrella of EULAR-ESCISIT.

SUBJECTS

had primary chronic knee OA (ACR criteria) with pain during physical activity >or=30 mm for at least 48 hours. Clinical parameters were collected by a rheumatologist and an US examination of the painful knee was performed by a radiologist or rheumatologist within 72 hours of the clinical examination. Ultrasonographic synovitis was defined as synovial thickness >or=4 mm and diffuse or nodular appearance, and a joint effusion was defined as effusion depth >or=4 mm.

RESULTS

600 patients with painful knee OA were analysed. At US 16 (2.7%) had synovitis alone, 85 (14.2%) had both synovitis and effusion, 177 (29.5%) had joint effusion alone, and 322 (53.7%) had no inflammation according to the definitions employed. Multivariate analysis showed that inflammation seen by US correlated statistically with advanced radiographic disease (Kellgren-Lawrence grade >or=3; odds ratio (OR)=2.20 and 1.91 for synovitis and joint effusion, respectively), and with clinical signs and symptoms suggestive of an inflammatory "flare", such as joint effusion on clinical examination (OR=1.97 and 2.70 for synovitis and joint effusion, respectively) or sudden aggravation of knee pain (OR=1.77 for joint effusion).

CONCLUSION

US can detect synovial inflammation and effusion in painful knee OA, which correlate significantly with knee synovitis, effusion, and clinical parameters suggestive of an inflammatory "flare".

A randomised, double blind, placebo controlled, multicentre trial of combination therapy with methotrexate plus ciclosporin in patients with active psoriatic arthritis

OBJECTIVES

To evaluate the safety and efficacy of adding ciclosporin A (CSA) to the treatment of patients with psoriatic arthritis (PsA) demonstrating an incomplete response to methotrexate (MTX) monotherapy.

METHODS

In a 12 month, randomised, double blind, placebo controlled trial at five centres in three countries, 72 patients with active PsA with an incomplete response to MTX were randomised to receive either CSA (n = 38) or placebo (n = 34). Patients underwent full clinical and radiological assessment and, in addition, high resolution ultrasound (HRUS) was performed at one centre. An intention to treat (last observation carried forward) analysis was employed.

RESULTS

Some significant improvements were noted at 12 months in both groups. However, in the active but not the placebo arm there were significant improvements in swollen joint count, mean (SD), from 11.7 (9.7) to 6.7 (6.5) (p<0.001) and C reactive protein, from 17.4 (14.5) to 12.7 (14.3) mg/l (p<0.05) as compared with baseline. The Psoriasis Area and Severity Index (PASI) score improved in the active group (2 (2.3) to 0.8 (1.3)) as compared with placebo (2.2 (2.7) to 1.9 (2.8)), p<0.001, and synovitis detected by HRUS (33 patients, 285 joints) was reduced by 33% in the active group compared with 6% in the placebo group (p<0.05). No improvement in Health Assessment Questionnaire or pain scores was detected.

CONCLUSIONS

Synovitis detected by HRUS was significantly reduced. Combining CSA and MTX treatment in patients with active PsA, and a partial response to MTX, significantly improves the signs of inflammation but not pain or quality of life.

Imaging the joints in early rheumatoid arthritis

Radiography is the most widely utilized imaging modality for early rheumatoid arthritis, determination of radiographic progression remaining a crucial part of the evaluation of therapy. Conventional radiography is, however, insensitive for showing bone damage in early disease and is totally unsuitable for assessing synovial inflammation. The recognition of these limitations has led to intense interest in the multiplanar imaging capabilities of magnetic resonance imaging in rheumatoid arthritis and to an increasing use of ultrasonography for assessing synovitis and bone damage. This chapter discusses the role of radiography in early rheumatoid arthritis and the emerging use and role of magnetic resonance imaging and ultrasonography in evaluating synovitis and bone damage. The relationship between synovitis and bone damage is also addressed in the light of recent magnetic resonance imaging observations.

New approaches to imaging of early rheumatoid arthritis

Conventional radiology (CR) is a major tool for the diagnosis and assessment of early arthritis. However, CR does not image the primary pathology of rheumatoid arthritis (RA), i.e. the synovium, and is insensitive for radiological erosions. New techniques, particularly magnetic resonance imaging (MRI) and ultrasonography (US) have shown their potential to improve on the sensitivity of CR. This article reviews the current status of this approach in early disease.

Persistence of mild, early inflammatory arthritis: the importance of disease duration, rheumatoid factor, and the shared epitope

OBJECTIVE

To determine the factors that predict clinical outcome at 6 months for patients with mild, early inflammatory arthritis.

METHODS

Sixty-three patients with mild, untreated, early arthritis were given a single dose of corticosteroids at presentation. Administration was intramuscular if disease was polyarticular (n = 53) or intraarticular if patients had <5 synovitic joints (n = 10). The primary outcome measure was clinical disease remission or persistence of arthritis at 6 months following injection.

RESULTS

At 6 months following injection, 49 of the 63 patients (78%) had persistent inflammatory joint disease. The other 14 (22%) had clinical disease remission. Regression analysis showed that only disease duration was significantly associated with persistent arthritis (P < 0.05). The other significant factor (by chi-square test) was the presence of the shared epitope (SE). Of the patients fulfilling the American College of Rheumatology (ACR) criteria at presentation (51% of the total), 53% with disease duration of < or = 12 weeks at presentation had persistent disease 6 months later, compared with 94% of those who presented with disease duration of >12 weeks.

CONCLUSION

The strongest predictor of persistent disease was a disease duration of >12 weeks. Rheumatoid factor and SE were also predictors to a lesser extent. Patients who both fulfilled the ACR classification criteria for rheumatoid arthritis (RA) and had a short disease duration included some with an excellent prognosis. Therefore, 12 weeks may be a more appropriate disease duration to use for the RA classification criteria. Administering a bolus of corticosteroids may be a useful diagnostic/therapeutic approach.

The relationship between synovitis and bone changes in early untreated rheumatoid arthritis: a controlled magnetic resonance imaging study

OBJECTIVE

The interrelationship between synovitis and bone damage in rheumatoid arthritis (RA) is a subject of controversy. Using magnetic resonance imaging (MRI), this study followed the bone changes in early RA and determined their relationship to synovitis.

METHODS

Thirty-one patients with early RA who had swelling of the metacarpophalangeal (MCP) joints and 31 healthy control subjects with no clinical evidence of arthritis underwent MRI of the second through fifth MCP joints of the dominant hand by use of a 1.5T scanner. Coronal T1-weighted and T2-fat suppressed (FS) sequences were performed to evaluate bone edema, and gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA) pulse sequences were obtained to evaluate synovitis. Bony abnormalities were described as bone edema (low signal on T1-weighted sequences and intermediate/high signal on T2 FS sequences adjacent to the bone cortex) or as bone cysts (circular juxtacortical abnormalities with low signal on T1-weighted images and with very high signal on T2 FS sequences). Contrast and noncontrast MRI films were scored in a blinded manner, and Fisher's exact probability test was used to determine differences between groups.

RESULTS

Twenty-one of the 31 RA patients (68%) had bone edema, which was seen in 43 of 124 joints (35% of joints) and 3 of the 31 control subjects had bone edema seen in 3 of 124 joints (2% of joints) (P < 0.0001). Thirty RA patients (97%) had Gd-DTPA-confirmed MCP joint synovitis, and bone edema was seen in 40 of the 75 joints with Gd-DTPA-proven synovitis (53%), but in only 3 of 49 without (6%) (P < 0.0001).

CONCLUSION

MCP joint bone edema is present in the majority of patients with RA at presentation, but is seen only occasionally in normal control subjects. The fact that bone edema occurred rarely in the absence of synovitis in patients with RA suggests that bony changes in RA are secondary to synovitis.

A preliminary study of ultrasound aspiration of bone erosion in early rheumatoid arthritis

OBJECTIVE

To develop a new technique to assess the primary lesion in early rheumatoid arthritis (RA).

METHODS

Ten patients with early RA and radiographically or MRI confirmed erosions had a needle introduced into the base of the erosion under sonographic guidance. Material was then aspirated from this site.

RESULTS

The procedure was well tolerated with no complications. Small samples of necrotic bone and tissue were obtained in five out of 10 cases. In one case, a distinctive population of pleomorphic CD34 + cells with characteristics of bone marrow progenitors was isolated. Tissue invading bone with a characteristic appearance of pannus was not seen.

CONCLUSION

A new method of sampling the earliest lesion in RA is described. The findings raise questions about the nature of bone damage in early RA.

Inhibition of the effector phase of IgE-mediated allergies by tolerogenic conjugates of allergens and monomethoxypolyethylene glycol

In this study we established that the conjugate of ovalbumin (OVA), which was used as a model allergen, with monomethoxypolyethylene glycol (mPEG), i.e., OVA(mPEG)11, was not only tolerogenic and essentially non-allergenic, but also capable of inactivating mast cells sensitized with anti-OVA IgE antibodies (Abs). Moreover, mast cells sensitized with a mixture of anti-OVA and anti-DNP IgE Abs were also desensitized by OVA(mPEG)11 with respect to both sensitivities. Most importantly, treatment of OVA-sensitive mice by OVA(mPEG)11 protected them from systemic anaphylaxis on challenge with OVA. The possibility of inactivating IgE-sensitized mast cells with mPEG conjugates of single epitopes of a given allergen is being investigated.