Power Doppler signal at the enthesis and bone erosions are the most discriminative OMERACT ultrasound lesions for SpA: results from the DEUS (Defining Enthesitis on Ultrasound in Spondyloarthritis) multicentre study

OBJECTIVES

To assess, in spondyloarthritis (SpA), the discriminative value of the Outcome Measures in Rheumatology (OMERACT) ultrasound lesions of enthesitis and their associations with clinical features in this population.

METHODS

In this multicentre study involving 20 rheumatology centres, clinical and ultrasound examinations of the lower limb large entheses were performed in 413 patients with SpA (axial SpA and psoriatic arthritis) and 282 disease controls (osteoarthritis and fibromyalgia). 'Active enthesitis' was defined as (1) power Doppler (PD) at the enthesis grade ≥1 plus entheseal thickening and/or hypoechoic areas, or (2) PD grade >1 (independent of the presence of entheseal thickening and/or hypoechoic areas).

RESULTS

In the univariate analysis, all OMERACT lesions except enthesophytes/calcifications showed a significant association with SpA. PD (OR=8.77, 95% CI 4.40 to 19.20, p<0.001) and bone erosions (OR=4.75, 95% CI 2.43 to 10.10, p<0.001) retained this association in the multivariate analysis. Among the lower limb entheses, only the Achilles tendon was significantly associated with SpA (OR=1.93, 95% CI 1.30 to 2.88, p<0.001) in the multivariate analyses. Active enthesitis showed a significant association with SpA (OR=9.20, 95% CI 4.21 to 23.20, p<0.001), and unlike the individual OMERACT ultrasound lesions it was consistently associated with most clinical measures of SpA disease activity and severity in the regression analyses.

CONCLUSIONS

This large multicentre study assessed the value of different ultrasound findings of enthesitis in SpA, identifying the most discriminative ultrasound lesions and entheseal sites for SpA. Ultrasound could differentiate between SpA-related enthesitis and other forms of entheseal pathology (ie, mechanical enthesitis), thus improving the assessment of entheseal involvement in SpA.

'Double target' ultrasound monitoring of biologic therapy in psoriatic arthritis

OBJECTIVES

We aimed to 1) evaluate by power Doppler (PD) ultrasound (US) the response to therapy of the most inflamed joint and enthesis (target sites) in psoriatic arthritis (PsA) patients starting a biologic disease-modifying anti-rheumatic drug (bDMARD); and 2) to investigate the correlation between the US response and clinical data.

METHODS

Consecutive PsA patients with US synovitis and US 'active' enthesitis, starting a bDMARD, were included. The joint with the highest OMERACT-EULAR-US composite score and the enthesis with the highest PD grade (targets) were identified at baseline. The US examination and clinical assessment were performed at 0, 3 and 6 months. The response of OMERACT-EULAR-US synovitis composite score was defined as reaching a grade = 0 at follow-up examination; synovial and entheseal PD responses were defined as a PD=0 and/or a reduction of ≥2 PD grades at follow-up examination.

RESULTS

Thirty patients were included. Synovitis composite score, synovial PD and entheseal PD showed significant responses at 3 and 6 months compared to baseline (p<0.01). Synovial PD responses were higher than entheseal PD responses at 3 months (71.4% vs 40.0%, p=0.01) and 6 months (77.8% vs. 46.7%, p=0.02). US synovitis responses were correlated with DAPSA (p<0.01) and MDA responses (p=0.01 for composite score, p=0.02 for PD).

CONCLUSIONS

US was found sensitive for monitoring treatment response in PsA patients starting a biologic drug. Entheseal PD was less responsive than synovial PD, suggesting that enthesitis may represent a 'difficult-to-treat' domain in PsA.

Diagnosis of calcium pyrophosphate crystal deposition disease by ultrasonography: how many and which sites should be scanned?

OBJECTIVE

To develop the optimal US scanning protocol for the diagnosis of CPPD disease.

METHODS

In this cross-sectional study, consecutive patients with a crystal-proven diagnosis of CPPD disease, and age-, sex-matched disease controls and with a negative synovial fluid analysis were prospectively enrolled in two Italian Institutions. Four rheumatologists, blinded to patients' clinical details, performed US examinations using a standardised scanning protocol including 20 joints (shoulders, elbows, wrists, metacarpophalangeal joints from 2nd to 5th fingers, hips, knees, ankles). CPPD was identified as presence/absence, according to the OMERACT definitions. Reduced US scanning protocols were developed by selecting the most informative joints to be imaged by US using the LASSO technique. Patients were randomly divided into training and validation sets. Their diagnostic accuracy was tested comparing the area under the ROC curves.

RESULTS

204 participants were enrolled: 102 with CPPD disease and 102 disease controls [age (mean±standard deviation) 71.3 ± 12.0 vs 71.1 ± 13.5 years, female: 62.8% vs 57.8%].The median number of joints with US evidence of CPPD was 5 (IQR: 4-7) and 0 (IQR: 0-1) in patients with CPPD disease and controls, respectively (p< 0 01).The detection of CPPD in ≥ 2 joints using a reduced scanning protocol (bilateral assessment of knees, wrists, and hips) showed a sensitivity of 96.7% (95%CI: 82.8-99.9) and a specificity of 100 (95%CI: 88.8-100.0) for the diagnosis of CPPD disease and had good feasibility [(mean±standard deviation) 12.5 ± 5.3 min].

CONCLUSION

Bilateral US assessment of knees, wrists, and hips had excellent accuracy and good feasibility for the diagnosis of CPPD disease.

Ultrasound in the Management of Patients With Psoriatic Arthritis: Systematic Literature Review and Novel Algorithms for Pragmatic Use

OBJECTIVE

In 2015, the European Alliance of Associations for Rheumatology (EULAR) published recommendations for the use of imaging for the diagnosis and management of spondyloarthritis (SpA) in clinical practice. These recommendations included the use of ultrasound (US) in patients with psoriatic arthritis (PsA), but the management was not clearly distinguished from that of SpA. We aimed to systematically review the literature on the role of US for the management of PsA, and to propose pragmatic algorithms for its use in clinical practice.

METHODS

A group of 10 rheumatologists, experienced in imaging and musculoskeletal US, met with the objectives of formulating key questions for a systematic literature review (SLR), appraising the available evidence, and then proposing algorithms on the application of US in suspected or established PsA, based on both the literature and experts' opinions following a Delphi process.

RESULTS

The SLR included 120 articles, most of which focused on the diagnostic process. The elevated number of articles retrieved suggests the interest of rheumatologists in using US in the management of PsA. After a consensual discussion on literature data and expert opinion, the following 3 algorithms were developed to be used in practical situations: suspicion of PsA, management of PsA with good clinical response, and management of PsA with insufficient clinical response.

CONCLUSION

The SLR showed interest by rheumatologists in using US to objectively evaluate PsA for diagnosis and management. We propose 3 practical algorithms to guide its use in the clinical management of patients, from diagnosis to the assessment of treatment response. Further studies are needed to define remission and to assess the ability of US to predict disease severity.

Multimodal ultrasound muscle assessment in patients with rheumatic diseases: a patient-based reliability study

Objectives

The aim was to explore the inter-reliability of a newly developed US scanning protocol (multimodal US) for the assessment of different aspects of sarcopenia-related muscle involvement, including muscle mass, muscle quality and muscle stiffness [using point shear-wave elastography (SWE)], in patients with rheumatic and musculoskeletal diseases (RMDs).

Methods

Quadriceps muscle mass (i.e. muscle thickness), muscle quality (i.e. muscle echogenicity evaluated with both a visual semi-quantitative scale and a dedicated software package for image analysis, ImageJ) and point SWE measurements were obtained by two rheumatologists (blinded to each other's evaluation) in consecutive RMD patients without previous/current myositis or neuromuscular disorders.Inter-reliability was assessed using the intraclass correlation coefficient (ICC) for continuous variables and Cohen's kappa (κ) for categorical variables.

Results

A total of 45 RMD patients were enrolled [mean age 54.5 (16.0) years, male-to-female ratio 1:1.5, mean BMI 24.6 (4.6) kg/m2], 10 with PsA, 7 RA, 5 AS, 5 PMR, 4 SLE, 4 gout, 4 OA, 3 FM and 3 SSc. The grade of inter-rater reliability was excellent for muscle mass [ICC = 0.969 (0.953 < ICC < 0.979)]. Regarding muscle echogenicity, the agreement was substantial/almost perfect using the visual semi-quantitative scale (weighted linear = 0.793, weighted squared = 0.878) and excellent using ImageJ analysis [ICC = 0.916 (0.876 < ICC < 0.944)]. Finally, a good agreement was obtained for point SWE measurements [ICC = 0.76 (0.712 < ICC < 0.8)].

Conclusion

Multimodal US is a novel and reliable tool for the evaluation of different aspects of muscle involvement (muscle mass, muscle quality and muscle stiffness) in RMD patients.

Dynamic assessment of the double contour sign by ultrasonography helps to distinguish between gout and calcium pyrophosphate deposition disease

OBJECTIVE

To test whether the double contour (DC) sign has a different dynamic behaviour in gout and calcium pyrophosphate deposition (CPPD) and whether the dynamic assessment of the DC sign increases its accuracy in gout diagnosis.

METHODS

This cross-sectional analysis included patients with gout meeting the 2015 ACR/EULAR classification criteria and patients with crystal-proven diagnosis of CPPD. Hyaline cartilages were explored by ultrasound (US) to detect the DC sign (ie, abnormal hyperechoic band over the superficial margin of hyaline cartilages) and its dynamic behaviour during joint movement was evaluated ((ie, movement of the DC sign together with subchondral bone (DC sign), or in the opposite direction (pseudo DC sign)).

RESULTS

Eighty-one patients with gout and 84 patients with CPPD underwent US assessment. Among them, 47 patients with gout and 9 patients with CPPD had evidence of the DC sign. During dynamic assessment, in all 47/47 patients with gout there was a DC sign. Conversely, in 7/9 (77.8%) patients with CPPD, there was a pseudo DC sign (p<0.01).The presence of DC sign during static assessment had a sensitivity, specificity and accuracy of 58.0% (95% CI 46.5% to 68.9%), 89.3% (95% CI 80.6% to 95.0%) and 73.9% (95% CI 66.5% to 80.5%) for gout, respectively. The dynamic evaluation improved the DC sign's diagnostic performance (p=0.01) as the specificity (97.6% (95% CI 91.7% to 99.7%)) and the accuracy (78.2% (95% CI 71.1% to 84.2%)) increased without loss in sensitivity.

CONCLUSION

The dynamic US assessment of the DC sign may help to differentiate the DC sign due to MSU crystals from the pseudo DC sign seen in CPPD, as they move in opposite directions.

Ultrasonography in the prediction of gout flares: a 12-month prospective observational study

OBJECTIVES

To evaluate whether US findings indicating MSU deposits and US-detected inflammation (i.e. power Doppler signal) predict gout flares over 12 months.

METHODS

Gout patients on urate-lowering therapy for at least the preceding 6 months were enrolled consecutively in this 12-month prospective, observational, single-centre study. A nested case-control analysis was performed. Cases were participants with at least one flare in the follow-up period, while controls did not self-report any gout flare. The US assessment included elbows, wrists, second MCP joints, knees, ankles, and first MTP joints. The US findings indicating MSU deposits [i.e. aggregates, double contour (DC) sign and tophi] were identified as present/absent according to the Outcome Measure in Rheumatology definitions. Power Doppler signal was scored semiquantitatively. Summated scores were calculated for each US finding.

RESULTS

Eighty-one gout participants were enrolled, and 71 completed the study. Thirty (42.3%) of 71 participants experienced at least one flare over 12 months, with a median of 2.0 flares. Cases had a greater US burden of MSU deposits (6.7 ± 4.7 vs 2.9 ± 2.6, P = 0.01) and power Doppler signal (3.73 ± 3.53 vs 0.82 ± 1.44, P < 0.01) than controls, at baseline. The baseline US scores indicating MSU deposits and US-detected inflammation were significantly associated with the occurrence (total MSU score, adjusted odds ratio:1.75, 95% CI: 1.26, 2.43; power Doppler score, adjusted odds ratio: 1.63, 95% CI: 1.12, 2.40) and the number (total MSU score, adjusted incidence risk ratio: 1.17, 95% CI: 1.08, 1.26; power Doppler score, adjusted incidence risk ratio: 1.29, 95% CI: 1.19, 1.40) of flares over 12 months in multivariate analyses.

CONCLUSIONS

Baseline US findings indicating MSU deposits and US-detected inflammation are independent predictors of gout flares over 12 months.

Reliability assessment of ultrasound muscle echogenicity in patients with rheumatic diseases: Results of a multicenter international web-based study

Objectives

To investigate the inter/intra-reliability of ultrasound (US) muscle echogenicity in patients with rheumatic diseases.

Methods

Forty-two rheumatologists and 2 radiologists from 13 countries were asked to assess US muscle echogenicity of quadriceps muscle in 80 static images and 20 clips from 64 patients with different rheumatic diseases and 8 healthy subjects. Two visual scales were evaluated, a visual semi-quantitative scale (0-3) and a continuous quantitative measurement ("VAS echogenicity," 0-100). The same assessment was repeated to calculate intra-observer reliability. US muscle echogenicity was also calculated by an independent research assistant using a software for the analysis of scientific images (ImageJ). Inter and intra reliabilities were assessed by means of prevalence-adjusted bias-adjusted Kappa (PABAK), intraclass correlation coefficient (ICC) and correlations through Kendall's Tau and Pearson's Rho coefficients.

Results

The semi-quantitative scale showed a moderate inter-reliability [PABAK = 0.58 (0.57-0.59)] and a substantial intra-reliability [PABAK = 0.71 (0.68-0.73)]. The lowest inter and intra-reliability results were obtained for the intermediate grades (i.e., grade 1 and 2) of the semi-quantitative scale. "VAS echogenicity" showed a high reliability both in the inter-observer [ICC = 0.80 (0.75-0.85)] and intra-observer [ICC = 0.88 (0.88-0.89)] evaluations. A substantial association was found between the participants assessment of the semi-quantitative scale and "VAS echogenicity" [ICC = 0.52 (0.50-0.54)]. The correlation between these two visual scales and ImageJ analysis was high (tau = 0.76 and rho = 0.89, respectively).

Conclusion

The results of this large, multicenter study highlighted the overall good inter and intra-reliability of the US assessment of muscle echogenicity in patients with different rheumatic diseases.

Doppler Signal and Bone Erosions at the Enthesis Are Independently Associated With Ultrasound Joint Erosive Damage in Psoriatic Arthritis

OBJECTIVE

To explore the association of the Outcome Measures in Rheumatology ultrasound (US) entheseal abnormalities with the presence of US joint bone erosions in psoriatic arthritis (PsA).

METHODS

Consecutive patients with PsA were included in this cross-sectional study. Demographic and clinical variables were collected. A bilateral US assessment was carried out at the following entheses: plantar fascia, and the quadriceps, patellar (proximal and distal), and Achilles tendons. The following US entheseal abnormalities were registered: hypoechogenicity, thickening, Doppler signal < 2 mm from the bony cortex, calcification/enthesophyte, and bone erosion. The presence of US joint bone erosions was investigated at the second and fifth metacarpophalangeal joints, ulnar head, and fifth metatarsophalangeal (MTP) joint, bilaterally, as well as at the level of the most inflamed joint on physical examination. Multiple linear regression analysis was performed to identify clinical and/or US variables associated with US-detected joint bone erosions.

RESULTS

A total of 104 patients with PsA were enrolled. At least 1 joint bone erosion was found in 47 of 104 patients (45.2%). Bone erosions were most frequently detected at the fifth MTP joint level (42/208 joints [20.2 %] in 32/104 patients [30.8%]). In the multivariate model, only a power Doppler (PD) signal at the enthesis (P < 0.001, standardized β = 0.51), bone erosions at the enthesis (P = 0.02, standardized β = 0.20), PsA disease duration (P = 0.04, standardized β = 0.17), and greyscale joint synovitis (P = 0.03, standardized β = 0.42) were associated with US-detected joint bone erosions.

CONCLUSION

PD signal and bone erosions at the enthesis represent sonographic biomarkers of a more severe subset of PsA in terms of US-detected joint erosive damage.

A real-world economic analysis of biologic therapies for psoriatic arthritis in Italy: results of the CHRONOS observational longitudinal study

BACKGROUND

Psoriatic arthritis (PsA) is a chronic, immune-mediated, spondyloarthropathy characterised by musculoskeletal signs and symptoms with associated joint pain and tenderness. The average worldwide PsA prevalence is 133/100,000, while in the Italian population is 90-420/100,000. Traditionally, nonsteroidal anti-inflammatory drugs, glucocorticoid, and disease-modifying antirheumatic drugs have been used in the treatment of PsA. However, for those patients who are not adequately controlled with conventional therapies, the new biologics compounds represent a valid option. Biologic therapies have been shown to be more effective but also more expensive than conventional systemic treatments. Based on the CHRONOS study, the economic analyses presented in this paper aim to assess the annualised direct costs and the cost-per-responder of biologics in a real-world context assuming the Italian National Health System perspective.

METHODS

The economic assessments were carried out on the overall cohort of patients, and on the tumour necrosis factor alpha inhibitors (TNFi) and the secukinumab subgroup, the most prescribed biologic therapies within the CHRONOS study.

RESULTS

The annual economic impact of PsA in the overall group was €12,622, €11,725 in the secukinumab subgroup, and €12,791 in the TNFi subgroup. Biologics absorbed the main expenditure costs in the treatment of PsA accounting for about the 93% of total costs. At 6 months, secukinumab performed better in all the considered outcomes: cost-per-responder according to EULAR DAS28 and ACR50 response criteria were €12,661- €28,975, respectively, while they were €13,356 - €33,368 in the overall cohort and €13,138 - €35,166 in the TNFi subgroup. At 12 months secukinumab remained the subgroup with the lowest cost-per-responder ratio in EULAR DAS28 and ACR50 response criteria, while TNFi subgroup was the lowest one considered the ACR20.

CONCLUSION

Despite some potential methodological limitations, our cost-per-response analysis provides physicians and payers additional insights which can complement the traditional risk-benefit profile assessment and drive treatment decisions.

Reliability assessment of the definition of ultrasound enthesitis in SpA: results of a large, multicentre, international, web-based study

OBJECTIVES

To investigate the reliability of the OMERACT US Task Force definition of US enthesitis in SpA.

METHODS

In this web exercise, based on the evaluation of 101 images and 39 clips of the main entheses of the lower limbs, the elementary components included in the OMERACT definition of US enthesitis in SpA (hypoechoic areas, entheseal thickening, power Doppler signal at the enthesis, enthesophytes/calcifications, bone erosions) were assessed by 47 rheumatologists from 37 rheumatology centres in 15 countries. Inter- and intra-observer reliability of the US components of enthesitis was calculated using Light's kappa, Cohen's kappa, Prevalence And Bias Adjusted Kappa (PABAK) and their 95% CIs.

RESULTS

Bone erosions and power Doppler signal at the enthesis showed the highest overall inter-reliability [Light's kappa: 0.77 (0.76-0.78), 0.72 (0.71-0.73), respectively; PABAK: 0.86 (0.86-0.87), 0.73 (0.73-0.74), respectively], followed by enthesophytes/calcifications [Light's kappa: 0.65 (0.64-0.65), PABAK: 0.67 (0.67-0.68)]. This was moderate for entheseal thickening [Light's kappa: 0.41 (0.41-0.42), PABAK: 0.41 (0.40-0.42)], and fair for hypoechoic areas [Light's kappa: 0.37 (0.36-0.38); PABAK: 0.37 (0.37-0.38)]. A similar trend was observed in the intra-reliability exercise, although this was characterized by an overall higher degree of reliability for all US elementary components compared with the inter-observer evaluation.

CONCLUSIONS

The results of this multicentre, international, web-based study show a good reliability of the OMERACT US definition of bone erosions, power Doppler signal at the enthesis and enthesophytes/calcifications. The low reliability of entheseal thickening and hypoechoic areas raises questions about the opportunity to revise the definition of these two major components for the US diagnosis of enthesitis.

Muscle involvement in systemic lupus erythematosus: multimodal ultrasound assessment and relationship with physical performance

OBJECTIVES

The objectives of this study were (1) to explore US findings for muscle mass, muscle quality and muscle stiffness in SLE patients and healthy subjects; (2) to investigate the relationship between the US muscle findings and physical performance in SLE patients and healthy subjects.

METHODS

Quadriceps muscle thickness was used for assessment of muscle mass, muscle echogenicity (using a visual semi-quantitative scale and grayscale analysis with histograms) for assessment of muscle quality, and point shear-wave elastography (SWE) for assessment of muscle stiffness in 30 SLE patients (without previous/current myositis or neuromuscular disorders) and 15 age-, sex- and BMI-matched healthy subjects. Hand grip strength tests and short physical performance battery (SPPB) tests were carried out in the same populations.

RESULTS

No difference was observed between SLE patients and healthy subjects for quadriceps muscle thickness (35.2 mm ±s.d. 6.8 vs 34.8 mm ± s.d. 6.0, respectively, P = 0.79). Conversely, muscle echogenicity was significantly increased in SLE patients (visual semi-quantitative scale: 1.7 ± s.d. 1.0 vs 0.3 ± s.d. 0.5, respectively, P < 0.01; grayscale analysis with histograms: 87.4 mean pixels ± s.d. 18.8 vs 70.1 mean pixels ± s.d. 14.0, respectively, P < 0.01). Similarly, SWE was significantly lower in SLE patients compared with healthy subjects {1.5 m/s [interquartile range (IQR) 0.3] vs 1.6 m/s (IQR 0.2), respectively, P = 0.01}. Muscle echogenicity was inversely correlated with grip strength (visual semi-quantitative scale, Rho: -0.47, P = 0.01; grayscale analysis with histograms, Rho: -0.41, p < 0.01) and SPPB (visual semi-quantitative scale, Rho: -0.50, P < 0.01; grayscale analysis with histograms Rho: -0,46, P < 0.01).

CONCLUSIONS

US assessment of muscle echogenicity and stiffness is useful for the early detection of muscle involvement in SLE patients.

The Reliability of Ultrasound in the Assessment of Hyaline Cartilage in Rheumatoid Arthritis and Healthy Metacarpal Heads

PURPOSE

 i) To assess the inter- and intra-observer reliability of ultrasound (US) in the evaluation of the hyaline cartilage (HC) of the metacarpal head (MH) in patients with rheumatoid arthritis (RA) and in healthy subjects (HS) both qualitatively and quantitatively. ii) To calculate the smallest detectable difference (SDD) of the MH cartilage thickness measurement. iii) To correlate the qualitative scoring system and the quantitative assessment.

MATERIALS AND METHODS

 US examination was performed on 280 MHs of 20 patients with RA and 15 HS using a very high frequency probe (up to 22 MHz). HC status was evaluated both qualitatively (using a five-grade scoring system) and quantitatively (using the average value of the longitudinal and transverse measures). The HC of MHs from II to V metacarpophalangeal joint of both hands were scanned independently on the same day by two rheumatologists to assess inter-observer reliability. All subjects were re-examined using the same scanning protocol and the same US setting by one sonographer after a week to assess intra-observer reliability.

RESULTS

 The inter-observer agreement and intra-observer agreement were moderate to substantial (k = 0.66 and k = 0.73) for the qualitative scoring system and high (ICC = 0.93 and ICC = 0.94) for the quantitative assessment. The SDD of the MH cartilage thickness measurement was 0.09 mm. A significant correlation between the two scoring systems was found (r = -0.35; p < 0.001).

CONCLUSION

 The present study describes the main methodological issues of HC assessment. Using a standardized protocol, both the qualitative and the quantitative scoring systems can be reliable.

Real-world evidence of biologic treatments in psoriatic arthritis in Italy: results of the CHRONOS (EffeCtiveness of biologic treatments for psoriatic artHRitis in Italy: an ObservatioNal lOngitudinal Study of real-life clinical practice) observational longitudinal study

Background

Biologics have demonstrated efficacy in PsA in randomized clinical trials. More evidence is needed on their effectiveness under real clinical practice conditions. The aim of the present work is to provide real-world evidence of the effectiveness of biologics for PsA in the daily clinical practice.

Methods

CHRONOS was a multicenter, non-interventional, cohort study conducted in 20 Italian hospital rheumatology clinics.

Results

399 patients were eligible (56.9% females, mean (SD) age: 52.4 (11.6) years). The mean (SD) duration of PsA and psoriasis was 7.2 (6.9) and 15.3 (12.2) years, respectively. The mean (SD) duration of the biologic treatment under analysis was 18.6 (6.5) months. The most frequently prescribed biologic was secukinumab (40.4%), followed by adalimumab (17.8%) and etanercept (16.5%). The proportion of overall responders according to EULAR DAS28 criteria was 71.8% (95% CI: 66.7–76.8%) out of 308 patients at 6 months and 68.0% (95% CI: 62.7–73.3%) out of 297 patients at 1 year. Overall, ACR20/50/70 responses at 6 months were 41.2% (80/194), 29.4% (57/194), 17.1% (34/199) and at 1-year were 34.9% (66/189), 26.7% (51/191), 18.4% (36/196), respectively. Secondary outcome measures improved rapidly already at 6 months: mean (SD) PASI, available for 87 patients, decreased from 3.2 (5.1) to 0.6 (1.3), the proportion of patients with dactylitis from 23.6% (35/148) to 3.5% (5/142) and those with enthesitis from 33.3% (49/147) to 9.0% (12/133).

Conclusions

The CHRONOS study provides real-world evidence of the effectiveness of biologics in PsA in the Italian rheumatological practice, confirming the efficacy reported in RCTs across various outcome measures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-022-00284-w.

In patients with acute mono-oligoarthritis, a targeted ultrasound scanning protocol shows great accuracy for the diagnosis of gout and CPPD

OBJECTIVES

To determine an ultrasound (US) scanning protocol with the best accuracy for the diagnosis of gout and CPPD in patients with acute mono/oligoarthritis of unknown origin.

METHODS

Patients with acute mono/oligoarthritis, in whom a joint aspiration at the most clinically involved joint (target joint) was requested, were consecutively enrolled. US was performed in each patient before the arthrocentesis. The accuracy of different US findings and scanning protocols for the diagnosis of gout and CPPD was calculated.

RESULTS

161 subjects were included (32 gout patients, 30 CPPD patients and 99 disease-controls).US findings had a high specificity for gout (0.92-0.96) and CPPD (0.90-0.97), while the sensitivity ranged from 0.73 to 0.85 in gout (double contour sign and tophi, respectively) and from 0.60 to 0.90 in CPPD (hyaline and fibrocartilage deposits, respectively). The US assessment of two joints bilaterally (gout: knees, MTP1js, CPPD: knees, wrists) + the target joint had an excellent diagnostic sensitivity (gout:0.91, CPPD:0.93) and specificity (gout:0.91, CPPD:0.89). This targeted US scanning protocol yielded to higher diagnostic accuracy compared to the US evaluation of the target joint (gout, AUC:0.91 vs AUC:0.84, p = 0.03; CPPD, AUC:0.93, vs AUC:0.84, p = 0.04) unless the target joint was the knee or the MTP1j in gout, and the knee or the wrist in CPPD.

CONCLUSIONS

A targeted US scanning protocol of two joints bilaterally + the target joint (unless this was the knee, MTP1j or the wrist) showed an excellent accuracy (>90%) for the diagnosis of crystal arthritis in patients with acute mono/oligoarthritis.

OP0167 ULTRASONOGRAPHY IN THE PREDICTION OF GOUT FLARES: A 12-MONTH PROSPECTIVE OBSERVATIONAL STUDY

Background

Gout flares are a distinctive feature of gout. Although imaging techniques, such as ultrasonography (US), can visualise monosodium urate (MSU) crystals and synovial inflammation and estimate their burden, the role of imaging in predicting gout flares has not been fully investigated.

Objectives

To evaluate whether US findings indicative of MSU deposits and subclinical inflammation predict gout flares over 12 months.

Methods

Participants with gout on urate-lowering therapy (ULT) for at least the preceding six months were enrolled consecutively in this 12-month prospective, observational, single-centre study.

A nested case-control analysis was performed. Cases were participants with at least one gout flare in the follow-up period while controls did not self-report any gout flares.

Clinical assessment was scheduled at 6-month intervals. In addition, at baseline, each patient underwent an US examination using a standardised scanning protocol including the following sites: knees, ankles, 1st metatarsophalangeal joints, elbows, wrists and 2nd metacarpophalangeal joints. The US findings indicating MSU deposits [i.e., aggregates, double contour (DC) sign and tophi] and inflammation [i.e., Power Doppler (PD) signal] were identified according to the 2015 Outcome Measure in Rheumatology definitions (Figure 1).

Figure 1.

Summated scores were calculated for each US finding.

During follow-up visits, patients were asked to report any gout flares using an internationally-validated definition [1].

Multivariate logistic regression analysis was used to measure the association between baseline US findings and the occurrence of gout flares over 12 months. US scores were tested separately, including the following covariates: age, gender, disease duration, presence of subcutaneous tophi, current serum urate>360 μmol/l, increasing dose of ULT during the study period and ongoing flare prophylaxis. In addition, multivariate zero-inflated Poisson regression analysis was used to investigate the association between US findings and the number of flares over 12 months.

Results

Eighty-one gout participants were enrolled, and 71 completed the study. Thirty (42.3%) of 71 participants experienced at least one flare over 12 months, with a median of 2.0 flares. There was no difference among baseline clinical and laboratory characteristics of patients with and without flares except for the presence of subcutaneous tophi (23.3% vs 4.9%; p=0.02) and higher current SU levels (360.8 vs 301.4 μmol/l mol/L, p=0.01).

Participants with flares had a greater baseline US burden of MSU deposits (2.0±1.8 vs 0.5±0.9, p=0.01 for DC sign; 2.1±2.3 vs 0.8±1.0, p=0.01 for tophi; 2.6±2.0 vs 1.6±1.6, p=0.03 for aggregates) and of subclinical inflammation (3.73±3.53 vs 0.82±1.44, p<0.01).

The baseline extent of MSU deposits and subclinical inflammation estimated by US was significantly associated with gout flares over 12 months in multivariate logistic regression analyses. DC sign score (aOR: 2.20, 95%CI: 1.22-4.34; p=0.01), tophi score (aOR: 2.16, 95%CI: 1.12-4.18; p=0.02) and PD score (aOR: 1.63, 95%CI: 1.12-2.40; p=0.01) predicted gout flares, whereas aggregates score (aOR: 1.40, 95%CI: 0.94-2.10; p=0.10) did not reach the statistical significance. Similar results were obtained in multivariate Poisson regression models (aIRR for DC score: 1.39, 95%CI: 1.18-1.64, p<0.01, aIRR for tophi score: 1.30, 95%CI: 1.17-1.45, p<0.01, aIRR for PD score: 1.29, 95%CI: 1.19-1.40, p<0.01, aIRR for aggregates score: 1.13, 95%CI: 1.00-1.29, p=0.05).

Conclusion

Baseline US findings indicating MSU deposits and subclinical inflammation are independent predictors of gout flares over 12 months.

References

[1]Gaffo AL, et al. Brief Report: Validation of a Definition of Flare in Patients With Established Gout. Arthritis Rheumatol. 2018;70:462-7.

Disclosure of Interests

None declared

Development of a convolutional neural network for the identification and the measurement of the median nerve on ultrasound images acquired at carpal tunnel level

Background

Deep learning applied to ultrasound (US) can provide a feedback to the sonographer about the correct identification of scanned tissues and allows for faster and standardized measurements. The most frequently adopted parameter for US diagnosis of carpal tunnel syndrome is the increasing of the cross-sectional area (CSA) of the median nerve. Our aim was to develop a deep learning algorithm, relying on convolutional neural networks (CNNs), for the localization and segmentation of the median nerve and the automatic measurement of its CSA on US images acquired at the proximal inlet of the carpal tunnel.

Methods

Consecutive patients with rheumatic and musculoskeletal disorders were recruited. Transverse US images were acquired at the carpal tunnel inlet, and the CSA was manually measured. Anatomical variants were registered. The dataset consisted of 246 images (157 for training, 40 for validation, and 49 for testing) from 103 patients each associated with manual annotations of the nerve boundary. A Mask R-CNN, state-of-the-art CNN for image semantic segmentation, was trained on this dataset to accurately localize and segment the median nerve section. To evaluate the performances on the testing set, precision (Prec), recall (Rec), mean average precision (mAP), and Dice similarity coefficient (DSC) were computed. A sub-analysis excluding anatomical variants was performed. The CSA was automatically measured by the algorithm.

Results

The algorithm correctly identified the median nerve in 41/49 images (83.7%) and in 41/43 images (95.3%) excluding anatomical variants. The following metrics were obtained (with and without anatomical variants, respectively): Prec 0.86 ± 0.33 and 0.96 ± 0.18, Rec 0.88 ± 0.33 and 0.98 ± 0.15, mAP 0.88 ± 0.33 and 0.98 ± 0.15, and DSC 0.86 ± 0.19 and 0.88 ± 0.19. The agreement between the algorithm and the sonographer CSA measurements was excellent [ICC 0.97 (0.94–0.98)].

Conclusions

The developed algorithm has shown excellent performances, especially if excluding anatomical variants. Future research should aim at expanding the US image dataset including a wider spectrum of normal anatomy and pathology. This deep learning approach has shown very high potentiality for a fully automatic support for US assessment of carpal tunnel syndrome.

Ultrasound-Guided Procedures in Rheumatology Daily Practice: Feasibility, Accuracy, and Safety Issues

BACKGROUND/OBJECTIVE

The aims of this study were to describe in detail the ultrasound (US)-guided procedures in our daily rheumatology practice, to evaluate the feasibility and accuracy of US-guided procedures, and to test the efficacy of our disinfection protocol in preventing infectious complications.

METHODS

This was a cross-sectional and monocentric study. Information regarding patients' age, sex, body mass index, rheumatic disease, US pathological findings, aspirated and/or injected anatomical site, US equipment (ie, probe type and frequency), and needle type was consecutively collected for each US-guided procedure in a third-level rheumatology center.

RESULTS

A total of 643 US-guided procedures were performed, with a mean of 5.2 procedures per working-day. In 94.2% of the patients, only one procedure was carried out, whereas in 5.8%, more than one. The mean time was 7 ± 2.5 minutes. Ultrasound-guided procedures were highly accurate (accuracy rate higher than 95%) and safe (adverse events were reported in 0.8%). Our disinfection protocol was effective in preventing infectious complications. Probes with frequency values between 8 to 13 MHz and 20-, 21-, and 22-gauge needles were the most frequently used at shoulder, knee, wrist, elbow, and ankle level. High-frequency linear probes (ranging between 18 and 22 MHz) and 23- and 25-gauge needles were used for injecting small joints of the hands and feet. Convex low-frequency probe (2-7 MHz) and 18- and 20-gauge needles were the most used for performing hip joint aspirations and/or injections.

CONCLUSIONS

This study reports useful information for setting up a service providing US-guided procedures in rheumatology and supports the feasibility, accuracy, and safety of US-guided procedures.

Enthesitis in Psoriatic Arthritis, the Sonographic Perspective

Purpose of Review

To provide an overview of the ultrasound (US) studies focusing on enthesitis in psoriatic arthritis (PsA).

Recent Findings

Last-generation US equipment has demonstrated the ability to detect subtle morphostructural and vascular abnormalities at entheseal level. US is able to identify pathologic changes in both “classical” (i.e., the site of attachment of tendons, ligaments, and joint capsules into the bone) and “functional” entheses (i.e., anatomical regions where tendons or ligaments wrap around bony pulleys).

Summary

US has the potential to be the first-line method in the assessment of enthesitis. In the present review we critically discussed the current definitions of US enthesitis, the scoring systems, and the main fields of application (i.e., the detection of enthesitis in PsA and psoriasis, the identification of different disease subsets, and the assessment of response to treatment).

Sonographic estimation of monosodium urate burden predicts the fulfillment of the 2016 remission criteria for gout: a 12-month study

Objective

To investigate whether baseline monosodium urate (MSU) burden estimated by ultrasound (US) predicts the achievement of the 2016 remission criteria for gout after 12 months.

Methods

In this 12-month prospective, observational and single-center study, patients with gout fulfilling all the domains of the 2016 preliminary remission criteria for gout at baseline and on urate-lowering therapy (ULT) for at least the preceding 6 months were consecutively enrolled.

The US findings indicative of MSU deposits [aggregates, double contour (DC) sign, and/or tophi] were identified according to the Outcome Measure in Rheumatology US Working Group definitions.

The US MSU burden was estimated by evaluating elbows, wrists, 2nd metacarpophalangeal joints, knees, ankles, and 1st metatarsophalangeal joints.

Results

Remission criteria were fulfilled in 21 (42.0%) out of 50 patients at 12 months. The baseline US MSU burden was significantly lower in patients who achieved remission than in those who did not fulfill the remission criteria at 12 months (1.9±1.8 vs 5.1±3.1, p<0.01).

US scores and ongoing flare prophylaxis were the only significant predictors of remission with an odds ratio of 10.83 [(95%CI=1.14–102.59), p=0.04] for the absence of MSU deposits, 5.53 [(95%CI=1.34–22.76), p<0.01] for the absence of aggregates, 7.33 [(95%CI=1.71–31.44), p<0.01] for the absence of DC sign, 3.88 [(95%CI=1.08–13.92), p=0.04] for the absence of tophi, and 0.23 [(95%CI=0.07–0.75), p=0.02] for ongoing flare prophylaxis.

Conclusion

In gout, baseline US estimation of MSU burden is an independent predictor of the achievement of the remission criteria at 12 months.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-021-02568-x.

Ultrasound definition of enthesitis in spondyloarthritis and psoriatic arthritis: arrival or starting point?

Enthesitis has a key role in the diagnosis, classification and management of patients with spondyloarthritis and psoriatic arthritis. Clinical assessment of enthesitis is known to be inaccurate mainly due to its poor specificity. In this context, ultrasound has the potential to improve the evaluation of enthesitis and, therefore, the management of patients with spondyloarthritis and psoriatic arthritis. In this viewpoint, we review the Outcome Measures in Rheumatology (OMERACT) definitions for ultrasound enthesitis, highlighting their current limits and potential implications on rheumatology research and clinical practice.

Sonographic assessment of cartilage damage at metacarpal head in rheumatoid arthritis: qualitative versus quantitative methods

OBJECTIVE

To test the validity of the Outcome Measure in Rheumatology (OMERACT) semiquantitative score by comparing with a quantitative method in the sonographic (US) assessment of hyaline cartilage at the metacarpal head (MH) in patients with rheumatoid arthritis (RA) and healthy subjects (HS).

METHODS

The hyaline cartilage from second to fifth MHs of both hands was scanned. Hyaline cartilage was scored semiquantitatively and quantitatively (by measuring cartilage thickness and comparing with reference values). In RA patients, radiographic joint space narrowing (JSN) was scored on the same joints using the Simple Erosion Narrowing Score (SENS).

RESULTS

Four-hundred and eight MHs in 51 RA patients and 320 MHs in 40 HS were evaluated. The OMERACT semiquantitative score was quicker to perform than the quantitative method (6.0 ± 0.5 vs 8.0 ± 1.5 min, p< 0.01). A significant correlation between the US scores (R = 0.68), and between the US scores and the JSN-SENS (R = 0.61 and R = 0.63, for semiquantitative and quantitative method, respectively) was found. The frequency of cartilage abnormalities was similar between the two US methods in RA patients (58.8% and 51.0% RA patients for semiquantitative and quantitative method, p= 0.46), while the former revealed more abnormalities in HS (27.5% and 7.5% of HS, p= 0.02).

CONCLUSION

The higher feasibility of the OMERACT semiquantitative score suggests its use as first-choice method in the evaluation of cartilage damage. However, despite its limits, the quantitative assessment of HC, providing patient-tailored information due to age- and sex-corrected cut-off values, may represent a valid supplement for optimizing the evaluation of cartilage damage in selected cases.

OP0209 SONOGRAPHIC ESTIMATION OF MONOSODIUM URATE BURDEN PREDICTS THE FULFILMENT OF THE 2016 REMISSION CRITERIA FOR GOUT: A 12-MONTH STUDY

Background:

Preliminary remission criteria for gout include the following five domains: serum uric acid (SUA) levels <360 µmol/l, absence of subcutaneous tophi, absence of gouty flares, pain (due to gout) <2/10 and patient global assessment of disease activity <2/10 [1]. To achieve remission, all criteria must be fulfilled at least twice in a 12-month period [1]. Although imaging techniques allow to visualise monosodium urate (MSU) deposits and to estimate their burden, an imaging domain was not included.

Objectives:

To investigate whether baseline MSU burden estimated by ultrasonography (US) predicts the achievement of remission according to these criteria [1] over 12 months.

Methods:

In this 12-month prospective, observational and monocentric study, patients with gout according to the 2015 ACR/EULAR criteria and on urate-lowering therapy for at least the preceding 6 months were consecutively recruited. After the baseline clinical assessment, only patients fulfilling all domains of the remission criteria [1] (and therefore amenable to achieve the remission at 12 months) were followed up at 6-month intervals for one year.

The US findings indicative of MSU deposits were identified according to the OMERACT definitions. The following joints were included in the US scanning protocol: elbows, wrists, 2nd metacarpophalangeal joints, knees, ankles and 1st metatarsophalangeal joints. Sum scores of aggregates, double contour (DC) signs, and tophi were calculated separately, and a total score resulting from the sum of all elementary US findings was recorded.

Results:

Seventy patients with gout were recruited; of these, 20 (28.6%) were excluded at baseline because 13 (18.6%) did not satisfy the SUA domain, 11 (15.7%) tophus domain, 7 (10.0%) pain domain and 5 (7.1%) disease activity domain.

In the enrolled patients (Age: 59.9±14.8 years, female/male ratio: 1/49, disease duration: 6.5±6.6 years), remission criteria were fulfilled in 21 (42.0%) of 50 patients over 12 months.

No significant difference was found between patients fulfilling and not fulfilling the remission criteria at 12 months in all clinical and laboratory data except for the gout flare prophylaxis (7, 33.3% vs 20, 69.0%; p=0.02).

The baseline US MSU burden was significantly lower (total score 1.9±1.8) in patients in remission than in those not in remission at 12 months (total score 5.1±3.1) (p<0.01). The fulfilment of the remission criteria at 12 months was recorded in 87.5% of the patients without baseline US evidence of MSU deposits and in only 33.0% of those with at least one US finding indicating MSU deposits (p<0.01).

US scores and gout flare prophylaxis were the only significant predictors of remission in the univariate analyses (Table 1).

Table 1.

Predictive values of baseline data for the remission at 12 months.

OR (95%CI)P valueOngoing flare prophylaxis0.23 (0.07-0.75)0.02Total score=010.83 (1.14-102.59)0.04Aggregate score=05.53 (1.34-22.76)<0.01DC sign score=07.33 (1.71-31.44)<0.01Tophus score=03.88 (1.08-13.92)0.02

95%CI: 95% confidence interval; OR: odds ratio.

The risk of not fulfilling the remission criteria increased with the US burden of MSU deposits. For each 1-point increase in total score, aggregate score, DC sign score and tophus score, the risk increased by 1.81- (95%CI: 1.27-2.60), 1.73- (95%CI: 1.14-2.64), 4.16- (95%CI: 1.55-11.3) and 1.95-fold (95%CI: 1.07-3.56), respectively (Figure 1).

Conclusion:

Baseline US estimation of MSU burden is an independent predictor of gout clinical remission at 12 months. The absence of US MSU deposits was the most significant predictor of remission, whereas the US detection of DC sign in at least one joint of not achieving remission. Thus, performing an US examination in patients amenable to fulfil the remission criteria after 12 months may improve risk-stratification and inform management of these patients.

References:

[1]de Lautour H, et al. Development of Preliminary Remission Criteria for Gout Using Delphi and 1000Minds Consensus Excersices. Arthritis Care Res 2016;68:667–72

Disclosure of Interests:

Edoardo Cipolletta: None declared, Andrea Di Matteo: None declared, Walter Grassi Speakers bureau: Walter Grassi has received speaking fees from AbbVie, Celgene, Grünenthal, Pfizer and Union Chimique Belge Pharma., Emilio Filippucci Speakers bureau: Emilio Filippucci. has received speaking fees from AbbVie, Bristol-Myers Squibb, Janssen-Cilag, Novartis, Pfizer, Roche and Union Chimique Belge Pharma

OP0205 ULTRASOUND-DETECTED CALCIUM PYROPHOSPHATE CRYSTAL DEPOSITION: WHICH SITES SHOULD BE SCANNED?

Background:

In recent years, ultrasonography (US) has emerged as an accurate and reliable tool for the diagnosis of calcium pyrophosphate (CPP) deposition disease (CPPD) in daily practice. Previous studies analyzed the diagnostic value of US findings in different tissues and joints. However, no studies have investigated the optimal US scanning protocol in the diagnosis of CPPD at patient level.

Objectives:

To assess the diagnostic value of the combinations of OMERACT-defined US findings of CPPD in the upper and lower limbs and to select the best minimal combination of anatomic structures to be scanned for diagnosing CPPD in inter-critical periods.

Methods:

Patients with a crystal-proven diagnosis of CPPD and age- and sex-matched disease-controls were prospectively enrolled in this cross-sectional, monocentric, case-control study. All subjects underwent a bilateral US examination of 9 hyaline cartilages (HC), 6 fibrocartilages (FC), 5 tendons, 1 joint recess and 1 ligament as follows: shoulder (glenoid FC, humeral HC and acromioclavicular FC), elbow (humeral HC and triceps tendon), wrist (triangular FC, scapho-lunate ligament, volar recess of the radio-lunate joint), hand (HC of the metacarpophalangeal joints from 2nd to 5th finger), hip (acetabular FC and femoral HC), knee (femoral condyles’ HC, meniscal FC, patellar and quadriceps tendons), ankle (talar HC, Achilles tendon and plantar fascia). US assessment was carried-out by a rheumatologist blinded to clinical data. CPP deposits were identified as presence/absence, according to the OMERACT definitions [1].

Results:

Ninety-five patients were enrolled: 45 CPPD patients (age: 72±10.6 years, disease duration: 5.6±7.8 years, female/male ratio: 1.3) and 50 age- and sex-matched disease-controls (18 with rheumatoid arthritis, 13 with osteoarthritis, 10 with psoriatic arthritis and 9 with gout).

The FC of the medial and lateral meniscus were the most frequently involved targets of CPP deposits in cases (81.8% and 77.3% of patients, respectively), followed by the triangular FC of the wrist (68.2%), the HC of the femoral condyles (54.5%), the scapho-lunate ligament (52.3%) and the acetabular FC (50.0%). In all these anatomical targets, US findings indicative of CPP deposits were detected in a significantly higher percentage of cases than controls (p<0.01).

The US scanning protocols that showed the best balance between sensitivity and specificity, the most sensitive and the most specific were shown in Table 1.

Table 1.

Diagnostic performances of different US scanning protocols

Anatomical targetsSESPLH+LH-Knee meniscal FC and wrist triangular FC0.86(0.76-0.96)0.86(0.73-0.94)6.35(3.17-12.72)0.13(0.06-0.30)Knee meniscal FC, wrist triangular FC and hip acetabular FC0.93(0.82-0.99)0.82(0.69-0.91)5.19(2.85-9.42)0.08(0.03-0.24)Hip acetabular FC, knee femoral condyles’ HC andwrist scapho-lunate ligament0.67(0.51-0.80)0.96(0.86-0.99)16.67(4.22-65.82)0.35(0.23-0.53)

LH: likelihood ratio, SE: sensitivity, SP: specificity, US: ultrasonography.

In all US scanning protocols, each anatomical target was assessed bilaterally.

Figure 1 includes representative pictures showing CPP crystal deposits in different anatomical targets.

A: Wrist, longitudinal scan of the triangular FC complex.

B: Knee, longitudinal scan of the lateral meniscus.

C: Hip, longitudinal scan of the acetabular labrum FC,

D: Knee, longitudinal scan of the medial femoral condyle’s HC.

Arrows: CPP crystal deposits at FC, arrowhead: CPP crystal deposits at HC.

Conclusion:

Our results suggest that bilateral US assessment of knee, wrist and hip provided acceptable sensitivity and specificity for diagnosing CPPD.

References:

[1]Filippou G, et al. Identification of calcium pyrophosphate deposition disease (CPPD) by ultrasound: reliability of the OMERACT definitions in an extended set of joints-an international multiobserver study by the OMERACT Calcium Pyrophosphate Deposition Disease Ultrasound Subtask Force. Ann Rheum Dis. 2018;77:1194-9.

Disclosure of Interests:

Edoardo Cipolletta: None declared, Jacopo Di Battista: None declared, Walter Grassi Speakers bureau: Walter Grassi has received speaking fees from AbbVie, Celgene, Grünenthal, Pfizer and Union Chimique Belge Pharma., Emilio Filippucci Speakers bureau: Emilio Filippucci. has received speaking fees from AbbVie, Bristol-Myers Squibb, Janssen-Cilag, Novartis, Pfizer, Roche and Union Chimique Belge Pharma.

POS1066 IS ENTHESITIS A SONOGRAPHIC BIOMARKER OF DISEASE SEVERITY IN PSORIATIC ARTHRITIS? THE LINK BETWEEN ULTRASOUND ENTHESEAL ABNORMALITIES AND PERIPHERAL JOINT EROSIVE DAMAGE

Background:

Enthesitis is one of the hallmark of psoriatic arthritis (PsA). Ultrasound (US) accurately detects morphostructural abnormalities indicative of entheseal inflammation and structural damage. Interestingly, in a recent study, US-detected entheseal pathology appeared to be a potential marker of disease severity, being associated with higher radiographic score of structural damage at peripheral joint level. (1) However, a sub-analysis of the impact of each elementary finding of US enthesitis was not performed. Moreover, some US entheseal abnormalities (hypoechogenicity, thickening and calcification/enthesophyte) have been described as frequent findings in healthy subjects and patients with dysmetabolic conditions, undermining their specificity. (2) Thus, we hypothesized that their role as a sonographic biomarker of joint disease severity could be questioned.

Objectives:

The main aim of the present study was to explore the association between the US elementary findings of enthesitis defined by OMERACT [i.e. hypoechogenicity, thickening, Doppler signal, calcification/enthesophyte and bone erosion at enthesis] (3) and the presence of US-detected joint bone erosions in patients with PsA.

Methods:

Consecutive patients with PsA (CASPAR criteria) were included in this cross-sectional single-centre study. The scanning protocol included bilateral assessment of the main entheses of the lower limbs [plantar fascia, quadriceps, patellar (proximal and distal) and Achilles tendons]. The presence of US joint bone erosions was investigated in the following areas: 2nd and 5th metacarpophalangeal (MCP) joints, ulnar head and 5th metatarsophalangeal (MTP) joint, bilaterally, as well as the most inflamed joint at the physical examination. The US examination was carried out with a 6-18 MHz probe. Univariate and multivariate logistic analysis were performed to identify predictors of US joint bone erosions.

Results:

A total of 74 PsA patients were enrolled. The mean disease duration was 7.9±8.0 years. Joint bone erosions were found in 36/75 patients (48.0%), and in 71/600 joints (11.8%), most frequently in the 5th MTP joint (in 26/75 patients, 34.7%). The univariate analysis showed that entheseal bone erosions [odds ratio (OR) 27.1, 95% confidence interval (CI) 3.3-220.2, p value <0.01] and Doppler signal (OR 3.5, 95% CI 1.3 - 9.4, p value 0.01) were associated with joint bone erosions. Only entheseal bone erosions remained significantly associated with joint bone erosions in the multivariate analysis (Table 1).

Table 1.

Multivariate regression analysis: predictive value of the entheseal US findings for the presence of joint bone erosions.

OR (95% CI)P valueHypoechogenicity0.5 (0.1-3.4)0.45Thickening2.2 (0.6-8.3)0.27Doppler signal3.2 (0.9-10.8)0.06Calcification/enthesophyte1.1 (0.1-11.2)0.99Entheseal bone erosion24.2 (2.7-216.2)<0.01

Conclusion:

Entheseal bone erosion and, to a lesser extent, Doppler signal, were the only entheseal abnormalities correlated with the presence of US-detected joint bone erosions, representing potential sonographic biomarkers of disease severity in PsA.

References:

[1]Polachek A, Cook R, Chandran V, Gladman DD, Eder L. The association between sonographic enthesitis and radiographic damage in psoriatic arthritis. Arthritis Res Ther 2017; 15;19:189.

[2]Balint PV, Terslev L, Aegerter P, Bruyn GAW, Chary-Valckenaere I, Gandjbakhch F, et al. Reliability of a consensus-based ultrasound definition and scoring for enthesitis in spondyloarthritis and psoriatic arthritis: An OMERACT US initiative. Ann Rheum Dis 2018; 77(12):1730-5.

[3]Di Matteo A, Filippucci E, Cipolletta E, Martire V, Jesus D, Musca A, et al. How normal is the enthesis by ultrasound in healthy subjects? Clin Exp Rheumatol 2020;38:472-8.

Disclosure of Interests:

Gianluca Smerilli: None declared, Edoardo Cipolletta: None declared, Giulia Maria Destro Castaniti: None declared, Andrea Di Matteo: None declared, Marco Di Carlo: None declared, Erica Moscioni: None declared, Francesca Francioso: None declared, Walter Grassi Speakers bureau: W.G. has received speaking fees from AbbVie, Celgene, Grünenthal, Pfizer and UCB Pharma., Emilio Filippucci Speakers bureau: E.F. has received speaking fees from Abbvie, BMS, Janssen, Lilly, MSD, Novartis, Roche, Pfizer, UCB Pharma.

The sonographic identification of cortical bone interruptions in rheumatoid arthritis: a morphological approach

Bone erosions are the hallmark of structural damage in rheumatoid arthritis (RA). Among imaging techniques, ultrasonography (US) has emerged as an accurate, reliable, repeatable, low-cost and non-invasive imaging modality to detect erosive changes in RA. However, small interruptions of the cortical bone detectable by last generation US equipment do not necessarily represent bone erosions. According to the available data, in addition to cortical bone interruption itself, only a few morphological US findings have been proposed to define RA bone erosions. However, other additional features may be considered to facilitate the interpretation of US cortical bone interruptions in RA. These could be summarised using the following four domains: size, site, shape and scenery. This hypothesis article provides a critical literature review of US features characteristic of RA bone erosions and pictorial evidence supporting the potential role of a morphological analysis in the US identification of bone erosions in RA patients.

Plain language summary

The ultrasonographic morphology of cortical interruptions is helpful for the identification of bone erosions in rheumatoid arthritis: the "four Ss" approach Bone erosions are characteristic features of rheumatoid arthritis. They are associated with a more aggressive disease and with irreversible physical disability. In recent years, ultrasonography has emerged as an accurate and reliable technique for the detection of bone erosions, that appear as interruptions of the cortical bone with variable size. However, cortical bone interruptions do not necessarily represent bone erosions. Since bone erosions represent the earliest evidence of the destructive behaviour of RA, their identification is crucial.Besides the cortical interruption itself, only a few morphological ultrasonographic features were proposed to characterise bone erosions in rheumatoid arthritis.We believe that a morphological approach, including size, site, shape and scenery, may be considered to facilitate the interpretation of ultrasonographic cortical bone interruptions in rheumatoid arthritis.In this hypothesis article we carried out a critical review of the scientific literature and provided extensive pictorial evidence of the ultrasonographic spectrum of cortical interruptions supporting the potential role of considering the "four Ss" for the ultrasonographic identification of bone erosions in rheumatoid arthritis.

Artificial Intelligence for Ultrasound Informative Image Selection of Metacarpal Head Cartilage. A Pilot Study

Objectives: This study aims to develop an automatic deep-learning algorithm, which is based on Convolutional Neural Networks (CNNs), for ultrasound informative-image selection of hyaline cartilage at metacarpal head level. The algorithm performance and that of three beginner sonographers were compared with an expert assessment, which was considered the gold standard.

Methods: The study was divided into two steps. In the first one, an automatic deep-learning algorithm for image selection was developed using 1,600 ultrasound (US) images of the metacarpal head cartilage (MHC) acquired in 40 healthy subjects using a very high-frequency probe (up to 22 MHz). The algorithm task was to identify US images defined informative as they show enough information to fulfill the Outcome Measure in Rheumatology US definition of healthy hyaline cartilage. The algorithm relied on VGG16 CNN, which was fine-tuned to classify US images in informative and non-informative ones. A repeated leave-four-subject out cross-validation was performed using the expert sonographer assessment as gold-standard. In the second step, the expert assessed the algorithm and the beginner sonographers' ability to obtain US informative images of the MHC.

Results: The VGG16 CNN showed excellent performance in the first step, with a mean area (AUC) under the receiver operating characteristic curve, computed among the 10 models obtained from cross-validation, of 0.99 ± 0.01. The model that reached the best AUC on the testing set, which we named “MHC identifier 1,” was then evaluated by the expert sonographer. The agreement between the algorithm, and the expert sonographer was almost perfect [Cohen's kappa: 0.84 (95% confidence interval: 0.71–0.98)], whereas the agreement between the expert and the beginner sonographers using conventional assessment was moderate [Cohen's kappa: 0.63 (95% confidence interval: 0.49–0.76)]. The conventional obtainment of US images by beginner sonographers required 6.0 ± 1.0 min, whereas US videoclip acquisition by a beginner sonographer lasted only 2.0 ± 0.8 min.

Conclusion: This study paves the way for the automatic identification of informative US images for assessing MHC. This may redefine the US reliability in the evaluation of MHC integrity, especially in terms of intrareader reliability and may support beginner sonographers during US training.

Is the intima-media thickness of temporal and axillary arteries influenced by cardiovascular risk?

Objectives

To measure with US the intima-media thickness (IMT) of temporal (superficial, parietal and frontal branches) and axillary arteries in subjects without a diagnosis of GCA and/or PMR with different cardiovascular (CV) risk; and to assess the performance of previously proposed cut-off values for normal IMT.

Methods

Subjects ≥ 50 years without a diagnosis of GCA or PMR were included. Bilateral US of the temporal arteries, including the frontal and parietal branches, and axillary arteries was performed by two sonographers using a 10–22 MHz and 6–18 MHz probe. The following previously proposed cut-offs were considered: superficial temporal artery: 0.42 mm; frontal branch: 0.34 mm; parietal branch: 0.29 mm; axillary artery: 1.0 mm.

Results

A total of 808 arteries in 101 subjects were evaluated; of these, 31 (30.7%) were classified as very high CV risk, seven (6.9%) as high, 34 (33.7%) as moderate and 29 (28.7%) as low risk. Subjects with very high or high risk showed higher IMT than those with moderate or low risk in the superficial temporal arteries [0.23 (s.d. 0.07) vs 0.20 (s.d. 0.04), P &lt; 0.01] and in the axillary arteries [0.54 (s.d. 0.17) vs 0.48 (s.d. 0.10), P = 0.002]. The IMT was higher than the reference cut-off in 13/808 (1.6%) arteries, in ≥1 artery in 10/101 subjects (10.1%). Of these 10 subjects, 8 (80%) were classified as having very high or high risk.

Conclusion

Our results suggest that CV risk might influence the US-determined IMT of the temporal and axillary arteries in subjects without GCA. Therefore, in patients with suspected GCA, particular attention should be paid when measuring the IMT in those patients with very high/high CV risk.

Ultrasound measurement of muscle thickness at the anterior thigh level in rheumatology setting: a reliability study

Ultrasound (US) is a promising tool for assessing sarcopenia. We aimed to test in the rheumatology setting two US scanning protocols to measure muscle thickness (MT) at the anterior thigh level and to assess their feasibility and reliability. In the first phase of the study, three rheumatologists performed a US examination on 19 consecutive patients adopting two scanning protocols, namely the anterior superior iliac spine (ASIS) and the greater trochanter techniques. After consensus was obtained on the easiest scanning protocol to perform, two rheumatologists adopted only the ASIS technique in 40 consecutive patients. MT measurements were recorded as well as the time needed to complete each scanning protocol bilaterally. The median time needed to complete the US examination was under 5 minutes for each of the two techniques, with no significant difference between them (p = 0.64). In the first phase, we found an excellent inter-observer reliability of the proposed scanning protocols, with a higher but nonstatistically significant intraclass correlation coefficient (ICC) for the ASIS technique compared with the greater trochanter technique (ICC 0.97 vs. ICC 0.92, p = 0.05). The ASIS technique had a significantly higher intra-observer reliability (ICC 0.97 vs. ICC 0.92, p < 0.01). In the second phase, the ASIS technique confirmed on a larger sample its excellent inter-observer reliability, with an ICC of 0.96. The present study presents a novel tool for assessing sarcopenia and provides evidence in favor of feasibility and reliability of US measurement of MT at the anterior thigh level in rheumatology setting. Key Points • This study demonstrates that ultrasound (US) measurement of muscle thickness at the anterior thigh level is highly reliable, especially for the "anterior superior iliac spine (ASIS)" technique. • The short time needed to complete the US assessment highlights the feasibility of the proposed scanning protocols. • The simplicity and conciseness of the proposed techniques will allow other researchers and clinicians to use it for a fast assessment of sarcopenia.

Biologics in the treatment of calcium pyrophosphate deposition disease: a systematic literature review

The main aim of this systematic literature review (SLR) was to summarise the evidence in the use of biological therapies in calcium pyrophosphate deposition disease (CPPD). We performed a SLR using PubMed, Embase and Cochrane databases. Only studies reporting the efficacy of biologics in CPPD were selected. The search resulted in 83 articles; 11 were further evaluated in the SLR. Seventy-six patients were included: 2 received infliximab, whereas 74 anakinra. Anakinra was used in refractory disease (85.1%) or in patients with contraindications to standard treatments (23.0%). Clinical response to anakinra was observed in 80.6% of patients with acute and 42.9% of those with chronic CPPD. Short-term treatment was well tolerated and adverse events were reported in 4.1% of the cases. This review provides evidence in favour of the use of anakinra as a therapeutic option in patients with CPPD, especially in acute refractory CPPD or when standard treatments are contraindicated.

Ultrasound measurement of muscle thickness at the proximal forearm in a rheumatologic setting

OBJECTIVES

To provide a detailed description of the ultrasound (US) scanning protocol to measure the muscle thickness in the forearm and to test its feasibility and interobserver reliability.

METHODS

Four rheumatologists trained in musculoskeletal US carried out the examinations in 45 subjects (30 consecutively enrolled patients and 15 healthy subjects). Each of the four rheumatologists took two measurements of each forearm (radial muscle thickness and ulnar muscle thickness) and the time needed to complete the bilateral US assessment was recorded.

RESULTS

The mean time required to acquire all measurements in each subject was less than four minutes. We found an excellent interobserver reliability of the proposed scanning protocol, with an intraclass correlation coefficient (ICC) among the four sonographers of 0.97 (CI 0.95-0.98) for the right ulnar muscle thickness, an ICC of 0.97 (CI 0.94-0.98) for the left ulnar muscle thickness, an ICC of 0.93 (CI 0.89-0.96) for the right radial muscle thickness and an ICC of 0.95 (CI 0.91-0.97) for the left radial muscle thickness.

CONCLUSIONS

The results of this study provide evidence in favour of interobserver reliability and feasibility of US measurement of the forearm muscle thickness.

Ultrasound assessment of carpal tunnel in rheumatoid arthritis and idiopathic carpal tunnel syndrome

Objectives

To comparatively assess the sonographic spectrum of carpal tunnel syndrome (CTS) in patients with rheumatoid arthritis (RA) and in patients with idiopathic CTS.

Methods

Fifty-seven RA patients and 25 idiopathic CTS patients were consecutively enrolled. The diagnosis of CTS in RA patients was made according to clinical history and examination. The following sonographic findings were assessed at carpal tunnel level: median nerve cross-sectional area (CSA) at the carpal tunnel proximal inlet, finger flexor tendons tenosynovitis, radio-carpal synovitis and intraneural power Doppler (PD) signal.

Results

CTS was diagnosed in 15/57 RA patients (26.3%). Twenty-three RA wrists with CTS, 84 RA wrists without CTS and 34 idiopathic CTS wrists were evaluated. The average CSA of the median nerve was higher in idiopathic CTS than in RA wrists with CTS (17.7 mm² vs 10.6 mm², p < 0.01). A higher rate of inflammation of synovial structures (flexor tendons sheath and/or radio-carpal joint) was found in RA wrists with CTS compared with those without CTS (p = 0.04) and idiopathic CTS (p = 0.02). Intraneural PD signal was more common in CTS (in both RA and idiopathic CTS) wrists compared with wrists without CTS (p < 0.01).

Conclusion

The sonographic spectrum of CTS in RA patients is characterized by an inflammatory pattern, defined by the presence of finger flexor tendons tenosynovitis and/or radio-carpal joint synovitis. Conversely, a marked median nerve swelling is the dominant feature in idiopathic CTS. Intraneural PD signal is a frequent finding in both conditions.

Key Points • Carpal tunnel syndrome (CTS) associated with rheumatoid arthritis (RA) and idiopathic CTS have distinct ultrasound patterns. • The most characteristic sonographic features of CTS in RA patients are those indicative of synovial tissue inflammation at carpal tunnel level. Conversely, marked median nerve swelling is the dominant finding in idiopathic CTS. • Intraneural power Doppler signal is a frequent finding in both conditions. • In patients with CTS, differently from electrophysiology, US can provide clues prompting a rheumatology referral in case of prominent inflammatory findings at carpal tunnel level.

Power Doppler Ultrasound Assessment of A1 Pulley. A New Target of Inflammation in Psoriatic Arthritis?

Objective: To determine the prevalence of grey scale and power Doppler (PD) ultrasound (US) features of A1 pulley inflammation in a cohort of psoriatic arthritis (PsA) patients compared with rheumatoid arthritis (RA) patients.

Methods: Sixty patients (30 with PsA and 30 with RA) were consecutively enrolled. The main clinimetric indexes were recorded, and US assessment of A1 pulleys from second to fifth fingers bilaterally was carried out. The presence of A1 pulley inflammation, defined as PD signal within a thickened pulley, was registered.

Results: A1 pulley inflammation was found in 15 of 240 fingers (6.3%) of eight PsA patients (26.7%) and in one of 240 fingers (0.4%) of one RA patient (3.3%) (p < 0.01 and p = 0.03, respectively). Seven of eight PsA patients (88%) with at least one inflamed A1 pulley had a moderate/high disease activity score. The regression linear analysis (R² = 0.36, adjusted R² = 0.31) showed that A1 pulley inflammation was correlated with Disease Activity Index for Psoriatic Arthritis (DAPSA) (β = 0.43, p = 0.03).

Conclusion: US A1 pulley inflammation appears to be relatively common at patient level in PsA, seems to be a characteristic feature of PsA compared to RA, and correlates with DAPSA.

THU0420 ULTRASOUND SHOWS GREAT ACCURACY FOR THE DIAGNOSIS OF CRYSTAL ARTHRITIS IN PATIENTS WITH RECENT-ONSET SYNOVITIS

Background:

The value of ultrasound (US) in the diagnosis of crystal arthropathy, such as gout or calcium pyrophosphate deposition disease (CPPD), in patients with recent onset synovitis has been evaluated only by a few studies.

Objectives:

To investigate, in patients with acute arthritis, the accuracy of US for the diagnosis of crystal arthropathy.

Methods:

Consecutive patients with recent onset (<6 weeks) acute arthritis were enrolled. The US examinations were performed a rheumatologist blinded to clinical data. Calcium pyrophosphate and monosodium urate crystal deposits were identified in the joint affected by synovitis (target joint), as well as in the classic sites for gout and CPPD (set of joint) (Table 1), according to the OMERACT definitions.

Table 1.

Anatomical targets of ultrasound examination

GoutCPPDBothWristRadiocarpal jIntercarpal jTriangular FC complexScapho-lunate ligament/HandDC in the II MCPj HCDeposits within the II MCPj HCII MCPjKneePopliteal grooveDC in the femoral condyle’s HCMeniscal FCDeposits within the femoral condyles’ HCSupra-patellar recessesHipDC in the femoral head’s HCDeposits within the femoral head’s HCAcetabular FCHip jFootDC in the I MTPj HCDeposits within I MTPj HCI MTPj

Legend.DC: double contour,FC: fibrocartilage,HC: hyaline cartilage,MCPj: metacarpophalangeal joint,MTPj: metatarsophalangeal joint,j: joint.

Table 2.

Diagnostic accuracy of US and SFA

SensitivitySpecificityPositive LHRNegative LHRUS (target joint)Crystal arthritis0.84(0.7-0.93)0.91(0.8-0.97)9.5(4.1-22)0.2(0.1-0.3)CPPD0.91(0.71-0.99)0.91(0.80-0.97)10.2(4.4-23.8)0.1(0-0.4)Gout0.83(0.61-0.97)0.91(0.80-0.97)9.1(3.9-21.4)0.2(0.1-0.5)US (set of joints)Crystal arthritis0.96(0.85-0.99)0.87(0.76-0.95)7.6(3.8-15.3)0.1(0-0.2)CPPD1(0.85-1)0.88(0.76-0.95)8(4-16)0(0-0.2)Gout0.91(0.72-0.99)0.88(0.76-0.95)7.3(3.6-14.8)0.1(0-0.4)SFACrystal arthritis0.9(0.77-0.97)1(0.94-1)/0.1(0-0.2)CPPD0.90(0.7-0.99)1.0(0.94-1)/0.1(0-0.3)Gout0.91(0.71-0.99)1(0.94-1)/0.1(0-0.3)

Legend.LHR: likelihood ratio

SFA was performed in 67 knees (64.4%), 10 wrists (9.6%), 10 ankles (9.6%), 5 I MTP joints (4.8%), 5 hips (4.8%), 4 elbows (3.8%), 4 shoulders (3.8%).

The total agreement between US and SFA was excellent (93.8% in CPPD and 90.2% in gout). SFA positive/US negative results occurred in 1 patient with CPPD (1.2%) and in 4 patients with gout (4.9%). On the contrary, US positive/SFA negative results occurred in 4 patients with CPPD (4.9%) and in 4 patients with gout (4.9%).

The diagnostic accuracy of US and synovial fluid analysis (SFA) was evaluated taking the classification criteria for gout and CPPD as gold standard (1,2). Moreover, the US and SFA results were compared in the joints in which the SFA was performed.

Results:

One-hundred and four patients were enrolled: 22 CPPD patients, 23 with gout and 59 disease controls. Table 2 reports the diagnostic accuracy of US and SFA, using the classification criteria as gold standard.

Figure 1

provides a pictorial evidence of the US appearance of crystal deposits. A: anterior suprapatellar transverse scan of the femoral condylar HC. HC calcifications (arrows) B: anterior longitudinal scan of the hip. FC calcification (asterisk) C: anterior longitudinal scan of the ankle. DC sign (void arrow) . D: dorsal longitudinal scan of distal interphalangeal joint. DC sign (void arrow).

Conclusion:

US is useful for the diagnosis of gout and CPPD in patients with acute synovitis. Extending the US evaluation to the joints which are most commonly involved in gout and in CPPD, other than those affected by synovitis, increases the sensitivity of US.

References:

[1]Neogi T, et al. 2015 Gout classification criteria: an ACR/EULAR collaborative initiative. Ann Rheum Dis 2015

[2]McCarty D. CPPD Disease: Nomenclature and Diagnostic Criteria. Ann Intern Med 1977

Disclosure of Interests: :

Edoardo Cipolletta: None declared, Andrea Di Matteo Grant/research support from: the publication was conducted while Dr. Di Matteo was an ARTICULUM fellow, Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work., Walter Grassi Speakers bureau: Prof. Grassi reports personal fees from AbbVie, personal fees from Celgene, personal fees from Grünenthal, personal fees from Pfizer, personal fees from Union Chimique Belge Pharma, outside the submitted work.

THU0407 THE VALUE OF SONOGRAPHY IN THE INTERCRITICAL PHASE OF GOUT

Background:

Disease remission is the goal of therapy for many chronic rheumatic diseases. In 2016, provisional gout remission criteria were proposed (1). To the best of our knowledge, no studies have compared ultrasound (US) findings in gouty patients with and without remission.

Objectives:

To determine the prevalence of US pathologic findings in patients with gout fulfilling and not fulfilling the provisional remission criteria and to investigate the value of the US findings as predictors of a gouty flare within 6 months.

Methods:

Patients with a diagnosis of gout according to the 2015 classification criteria (2) were recruited in this prospective, monocentric study. The following clinical information was recorded at baseline and after 6 months: number of gouty flares in the preceding 6 months, number of subcutaneous tophi, current serum urate level, and patient reported outcomes (pain visual analogue scale and patient global assessment visual analogue scale). Bilateral US assessment of the following anatomical areas was performed (3): elbow, wrist, II metacarpophalangeal joint, knee, ankle and I metatarsophalangeal joint. US evidence of tophi, aggregates, double contour sign and synovitis were recorded according to the correspondent OMERACT definitions.

Results:

Forty-nine patients with gout were consecutively enrolled. The remission criteria were satisfied in 9 (18.4%) patients. Monosodium urate (MSU) deposits and findings of synovitis were observed by US less frequently in patients in remission (55.6% and 22.2%), compared with those not fulfilling the criteria (100.0% and 72.5%) (p values<0.01). The US MSU total score was 1.0; 0.0–2.0 (median and inter-quartile range) for patients in remission, compared with 6.0; 5.0–7.0 for those not fulfilling the criteria (p<0.01). US synovitis total score was significantly correlated with patient global assessment (R=0.55, p<0.01), patient pain (R=0.51, p<0.01) and number of gouty attacks in the previous 6 months (R=0.36, p=0.03), whereas MSU total score was associated with the number of gouty attacks in the previous 6 months (R=0.49, p<0.01), the number of subcutaneous tophi (R=0.45, p<0.01), patient pain (R=0.41, p=0.01), patient global assessment (R=0.41, p<0.01). At logistic regression analysis, the presence of subcutaneous tophi (OR=2.8, p=0.02), CRP level (OR=6.5, p=0.04) and US synovitis score (OR=2.0, p=0.04) and were predictors of subsequent development of gouty flare within 6 months.

Conclusion:

This study provides new insights into the inter-critical phase of gout, highlighting the clinical relevance of US synovitis as a predictor of subsequent development of gouty flare and joint pain. Despite MSU deposits are still detectable in patients satisfying the 2016 provisional remission criteria for gout, the remission is associated with less US detected MSU deposits.

References:

[1]de Lautour H, et al. Development of preliminary Remission Criteria for Gout Using Delphi and 1000Minds Consensus Exercises. Arthritis Care Res 2016

[2]Neogi T, et al. 2015 Gout classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis 2015

[3]Naredo E, et al. Ultrasound-detected musculoskeletal urate crystal deposition: which joints and what findings should be assessed for diagnosing gout? Ann Rheum Dis 2014

Disclosure of Interests: :

Edoardo Cipolletta: None declared, Andrea Di Matteo Grant/research support from: the publication was conducted while Dr. Di Matteo was an ARTICULUM fellow, Giada Brunori: None declared, Antonella Moretti: None declared, Walter Grassi Speakers bureau: Prof. Grassi reports personal fees from AbbVie, personal fees from Celgene, personal fees from Grünenthal, personal fees from Pfizer, personal fees from Union Chimique Belge Pharma, outside the submitted work., Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work.

THU0419 BIOLOGICS IN THE TREATMENT OF CALCIUM PYROPHOSPHATE DEPOSITION DISEASE. A SYSTEMATIC LITERATURE REVIEW

Background:

Only few case reports and case series have analysed the efficacy of IL-1 inhibitors in the treatment of calcium pyrophosphate deposition disease (CPPD), reporting conflicting results.

Objectives:

The main aim of this systematic literature review (SLR) was to summarize the evidence in the use of biological therapies in CPPD.

Methods:

PRISMA-IPD guidelines were used for this review. Published articles reporting the use of TNFα and/or IL-1 inhibitors in the treatment of CPPD were reviewed. We performed a SLR using PubMed, Embase and Cochrane databases. The search resulted in 83 articles; 11 were further evaluated in the SLR.

Results:

Seventy-six patients were included: 2 received infliximab, whereas 74 anakinra. The main data of included studies are reported in table 1.

Table 1.

Studies evaluating biological therapies in patients with CPPD.

AuthorsYear of publicationPopulation of interestNumber of CPPD patientsDiagnostic criteriaClinical presentationMcGonagle D. et al.2008CPPD1SFAChronicAnnoun N. et al.2009CPPD1SFAAcuteCouderc M. et al.2012CPPD3ImagingAcute and chronicDiamantopoulos A.P. et al.2012CPPD1SFAChronicMoltó A. et al.2012CPPD5SFAAcute and chronicOttaviani S. et al.2013CPPD16SFA and/or imagingAcuteVerhoeven F. et al.2013G and CPPD2NRAcute and chronicBruges-Armas J. et al.2014CPPD2NRChronicAouba A. et al.2015G, CPPD and HADD1ImagingAcuteDesmarais J. et al.2018G, CPPD11SFA and/or imagingAcuteThomas M. et al.2018CPPD32SFA and/or imagingAcute

Legend.G: gout,HADD: hydroxyapatite deposition disease,NR: not reported,SFA: synovial fluid analysis

Table 2.

Efficacy of anakinra in the treatment of CPPD

Acute CPPD (n=67)Chronic CPPD (n=7)Clinical efficacy (%)54 (80.6)3 (42.9)Pre TJC6.3±2.43.8±2.4Post TJC1.2±0.61.3±1.5Mean reduction5.1±2.3*2.5±1.9+Pre SJC4.8±2.23.8±2.4Post SJC1.1±0.61.3±1.5Mean reduction3.7±2.2*2.5±1.9+Pre VAS pain (0-100 mm)68.5±9.5/Post VAS pain (0-100 mm)24.2±10.4/Mean reduction44.2±10.9*/Pre CRP (mg/l)40.9±50.950.0±66.5Post CRP (mg/l)22.2±8.63.2±2.5Mean reduction18.6±54.1*46.7±64.0+

Legend. CRP: C-reactive protein,SJC: swollen joint count,TJC: tender joint count,VAS: visual analogue scale.+p values were not calculated because of a too small sample size. * p values were <0.01

Sixty-seven (88.2%) patients presented with an acute CPPD (mean disease duration: 2.7±6.9 months; polyarticular involvement in 61.2%, oligoarticular in 31.3% and monoarticular in 7.5%), whereas 9 (11.8%) patients with a chronic CPPD (mean disease duration: 130.1±133.6 months; polyarticular involvement in 66.7% and oligoarticular in 33.3%).

Anakinra was used in refractory disease (85.1%) or in patients with contraindications to standard treatments such as colchicine, oral glucocorticoids and/or non-steroidal anti-inflammatory drugs (23.0%). Clinical response to anakinra was reported in table 2.

Duration of anakinra treatment prior to complete resolution of symptoms was associated with the clinical phenotype of chronic CPPD (Rpb: 0.67, p<0.01) and with disease duration (R: 0.49, p<0.01). In 47 out of 57 (82.5%) responders, complete resolution of symptoms was observed within 4 days after the first injection of anakinra. Adverse events were reported in 4.1% of the cases: local skin reaction at the injection site, skin rash on the back and bacterial pneumonia.

Conclusion:

This SLR provides evidence in favour of the use of anakinra as a therapeutic option in patients with CPPD, especially in acute refractory CPPD or when standard treatments are contraindicated.

Disclosure of Interests: :

Edoardo Cipolletta: None declared, Andrea Di Matteo Grant/research support from: the publication was conducted while Dr. Di Matteo was an ARTICULUM fellow, Anna Scanu: None declared, Martina Isidori: None declared, Jacopo Di Battista: None declared, Leonardo Punzi: None declared, Walter Grassi Speakers bureau: Prof. Grassi reports personal fees from AbbVie, personal fees from Celgene, personal fees from Grünenthal, personal fees from Pfizer, personal fees from Union Chimique Belge Pharma, outside the submitted work., Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work.

SAT0439 POWER DOPPLER ULTRASOUND ASSESSMENT OF A1 PULLEY. A NEW TARGET IN PSORIATIC ARTHRITIS?

Background:

In the last few years annular pulleys inflammation has been highlighted as a possible key pathogenetic factor in psoriatic dactylitis, first with magnetic resonance imaging (MRI)1, then, in a very recent paper2, with power Doppler (PD) ultrasound (US). However, the prevalence of PD US inflammation of annular pulleys in psoriatic arthritis (PsA) patients compared to rheumatoid arthritis (RA) patients has not been investigated yet.

Objectives:

To determine the prevalence of PD US findings indicative of A1 pulley inflammation in PsA patients and in controls with RA and to preliminarily investigate the correlation between A1 pulley inflammation and disease activity (DAPSA).

Methods:

Consecutive patients with PsA and RA were included in this cross-sectional single-centre study. A rheumatologist recorded demographic and clinical data and in the same day another rheumatologist performed the US examination using a MyLab ClassC (Esaote, Genova, Italy) equipped with a 10-22 MHz linear probe. A1 pulleys of fingers 2ndto 5thwere assessed bilaterally adopting longitudinal and transverse scans. The following pathological US findings were recorded: inflammation of the pulley (defined as the presence of PD signal within a thickened pulley) and tenosynovitis of the digital flexor tendons at finger level according to OMERACT definition.

Results:

Sixty patients were enrolled: 30 with PsA and 30 with RA. Inflammation of A1 pulley was found in 15 out 240 fingers (6.3%) of 8 (26.7%) PsA patients and in 1 out of 240 fingers (0.4%) of 1 (3.3%) RA patients (p<0.01 and p=0.03 respectively). Both pulley inflammation and tenosynovitis were correlated with DAPSA (Rpb=0.56, p<0.01 and Rpb=0.48, p<0.01). In fact, 7 out 8 (88%) PsA patients with at least one inflamed A1 pulley had a moderate/high disease activity score. The regression linear analysis (R2=0.36, adjusted R2=0.31) showed that A1 pulley inflammation was correlated with higher DAPSA scores (β=0.43, p=0.03). No significant association was reported between A1 pulley inflammation and past or current episodes of dactylitis (p=0.09). However, the only current dactylitis assessed showed A1 pulley inflammation.

Conclusion:

This pilot study demonstrated that ultrasound A1 pulley inflammation, defined as the presence of power Doppler signal within a thickened pulley, is relatively common at patient level in psoriatic arthritis and seems to be characteristic of PsA compared to RA. In psoriatic arthritis patients, a positive significant correlation was found between ultrasound A1 pulley inflammation and disease activity.

References:

[1]Tan AL, Fukuba E, Halliday NA, Tanner SF, Emery P, McGonagle D. High-resolution MRI assessment of dactylitis in psoriatic arthritis shows flexor tendon pulley and sheath-related enthesitis. Ann Rheum Dis 2015; 74: 185-9.

[2]Tinazzi I, McGonagle D, Macchioni P, Aydin SZ. Power Doppler enhancement of accessory pulleys confirming disease localization in psoriatic dactylitis. Rheumatology (Oxford) 2019 [Epub ahead of print].

Disclosure of Interests:

Gianluca Smerilli: None declared, Edoardo Cipolletta: None declared, Marco Di Carlo: None declared, Andrea Di Matteo Grant/research support from: the publication was conducted while Dr. Di Matteo was an ARTICULUM fellow, Walter Grassi Speakers bureau: Prof. Grassi reports personal fees from AbbVie, personal fees from Celgene, personal fees from Grünenthal, personal fees from Pfizer, personal fees from Union Chimique Belge Pharma, outside the submitted work., Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work.

SAT0554 SONOGRAPHIC ASSESSMENT OF CALCIUM PYROPHOSPHATE DEPOSITION DISEASE AT WRIST. A FOCUS ON THE SCAPHO-LUNATE LIGAMENT

Background:

Only few articles evaluated the wrist in calcium pyrophosphate deposition disease (CPPD), although it is the second most frequent target of CPPD. Very recently, in a computed tomography (CT) study ligamentous calcifications were reported as a highly specific feature of CPPD at wrist level (1).

Objectives:

i) to determine the prevalence and distribution of the ultrasound (US) findings indicative of calcium pyrophosphate (CPP) crystal deposits at the wrist, with a particular focus on the dorsal aspect of the scapho-lunate ligament (SLL); ii) to investigate the diagnostic accuracy of US and conventional radiography (CR) in the evaluation of CPP crystal deposits at wrist level, iv) to assess the agreement between the different imaging techniques.

Methods:

Consecutive patients with a “definite” diagnosis of CPPD according to the Ryan and McCarty criteria and disease controls were prospectively included in this cross-sectional single-centre study. Dorsal part of the SLL, triangular fibrocartilage complex (TFCC), and volar recess of the radio-lunate joint were explored using US (according to EULAR standard scans and OMERACT definitions), CR and CT.

Results:

Sixty-one CPPD patients and 39 disease controls were enrolled. Two-hundred wrists were evaluated using both CR and US. CT data of 26 (13.0%) wrists were available: 20 wrists in CPPD patients and 6 wrists in controls. CPP crystal deposits were found by US in at least one wrist in 95.1% of CPPD patients and in 15.4% of controls (p<0.001). SLL calcification was reported in 83.6% of CPPD patients and in 5.1% of controls (p<0.001). CPP crystal deposits were observed by US at the SLL and/or radio-lunate joint in 5.7% of wrists and 6.6% of CPPD patients, but not at the TFCC of the same wrist. On CR, calcifications were found in at least one wrist in 72.1% of CPPD patients and in 0% of controls (p<0.001). Using the Ryan-McCarty criteria as a gold standard, the sensitivity, specificity and diagnostic accuracy were 0.72 (0.59-0.83), 1.0 (0.91-1.0) and 0.83 (0.74-0.90) for CR and 0.95 (0.86-0.99), 0.85 (0.69-0.94) and 0.91 (0.84-0.96) for US. Table 1 shows the agreement between the different imaging techniques.

Tabel 1.

Agreement between US and the other imaging techniques in the evaluation of CPP crystal deposits at the wrist.

US-CR (n=200)US-CT (n=26)TFCC0.55 (0.43-0.67)0.70 (0.43-0.97)SLL0.23 (0.07-0.39)0.69 (0.41-0.97)RLJ0.25 (0.09-0.41)0.46 (0.12-0.80)

Legend.n: number of the wrists,RLJ: volar recess of the radio-lunate joint. Values in brackets are the 95% confidence intervals of the Cohen’s kappa.

Figure 1

provides a pictorial evidence of the appearance of CPP crystal deposits in the SLL.A: CPP crystal deposits (curved arrow) at the TFCC. The SLL is not assessable due to superimposition of other bones.B: in the same patient of figure 1A, CT scan shows the presence of a calcification of the dorsal aspect of the SLL (arrow).C: dorsal longitudinal scan of the SLL: isolated hyperechoic spot (arrowheads) inside the ligament.D: dorsal longitudinal scan of the SLL showing the presence of a large aggregate extending towards the extensor tendons and hyperechoic spots (arrowheads) within it.Legend.iii: third extensor compartment,iv: fourth extensor compartment,l: lunate bone,s:scaphoid bone.

Conclusion:

This study supports the diagnostic accuracy of US in evaluating wrist involvement in CPPD patients. SLL calcifications are a specific US finding of CPPD at wrist level.

References:

[1]Ziegeler K, Diekhoff T, Hermann S, et al. Low-dose computed tomography as diagnostic tool in calcium pyrophosphate deposition disease arthropathy: focus on ligamentous calcifications of the wrist. Clin Exp Rheumatol 2019;37:826-33.

Disclosure of Interests:

Edoardo Cipolletta: None declared, Gianluca Smerilli: None declared, Riccardo Mashadi Mirza: None declared, Andrea Di Matteo Grant/research support from: the publication was conducted while Dr. Di Matteo was an ARTICULUM fellow, Fausto Salaffi Speakers bureau: Dr. Salaffi reports personal fees from Bristol Myers Squibb, personal fees from Pfizer, personal fees from Novartis, personal fees from AbbVie, personal fees from Roche, personal fees from Merck Sharp & Dohme Italia, outside the submitted work., Walter Grassi Speakers bureau: Prof. Grassi reports personal fees from AbbVie, personal fees from Celgene, personal fees from Grünenthal, personal fees from Pfizer, personal fees from Union Chimique Belge Pharma, outside the submitted work., Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work.

SAT0031 CORRELATION BETWEEN IRREVERSIBLE PHYSICAL DISABILITY AND JOINT DAMAGE IN RHEUMATOID ARTHRITIS

Background:

In rheumatoid arthritis (RA), irreversible physical disability appears to be more clearly associated with cartilage damage rather than with bone erosions (BE) using conventional radiography (CR) imaging.

Objectives:

To investigate the correlation between the ultrasound (US) and CR findings indicative of joint damage and irreversible physical disability in patients with RA in sustained clinical remission.

Methods:

Patients in sustained clinical remission according to the Simplified Disease Activity Index (SDAI)≤3.3 for at least 6 months were enrolled. The following data were regireted: age, disease duration, anti-cyclic citrullinated peptide (ACPA) antibody and rheumatoid factor (RF) status, Health Assessment Questionnaire (HAQ), CR of hands and feet [evaluated using the Simple Erosion Narrowing Score (SENS) method]. A standardized US examination was carried out to investigate the presence of BE (lateral side of II metacarpophalangeal, V metacarpophalangeal and V metatarsophalangeal joints and ulnar styloid) and of cartilage damage (II to V metacarpal heads), bilaterally. BE and cartilage damage were assessed according to OMERACT definitions. A semiquantitative scoring system for both BE (1) and cartilage damage (2) was adopted.

Results:

Ninety patients were consecutively enrolled. Average time for US evaluation was 10±2 minutes. Both SENS-JSN and US score of cartilage damage (US-CD) were significantly associated with irreversible disability (R=0.39, p<0.01 and R=0.46, p<0.01). US and CR showed a moderate agreement in the evaluation of cartilage damage (kappa=0.52, 95% confidence interval: 0.44-0.61).

Figure 1.

shows the association between disability and structural damage (A: US-CD, B: US-BE, C: SENS-JSN and D: SENS-BE). After adjusting for confounding factors (age, disease duration, ACPA and RF status, SENS-BE and US-BE) cartilage damage was the only significant predictor of irreversible disability both using CR (R2=0.31, adjusted R2=0.26, standardized β=0.36, p<0.01) and US (R2=0.31, adjusted R2=0.26, standardized β=0.34, p<0.01).

Conclusion:

This study supports the hypothesis that cartilage damage is more relevant than BE in determining irreversible disability in RA. Our data provide further evidence in favor of the external validity of US in the assessment of cartilage damage.

References:

[1] Ohrndorf S, Messerschmidt J, Reiche BE, et al. Evaluation of a new erosion score by musculoskeletal ultrasound in patients with rheumatoid arthritis: is US ready for a new erosion score? Clin Rheumatol. 2014;33:1255-62.

[2] Mandl P, Studenic P, Filippucci E, et al. Development of semiquantitative ultrasound scoring system to assess cartilage in rheumatoid arthritis. Rheumatology (Oxford). 2019;58:1802-11.

Disclosure of Interests:

Edoardo Cipolletta: None declared, Antonella Incorvaia: None declared, Riccardo Mashadi Mirza: None declared, Andrea Di Matteo Grant/research support from: the publication was conducted while Dr. Di Matteo was an ARTICULUM fellow, Marika Tardella: None declared, Walter Grassi Speakers bureau: Prof. Grassi reports personal fees from AbbVie, personal fees from Celgene, personal fees from Grünenthal, personal fees from Pfizer, personal fees from Union Chimique Belge Pharma, outside the submitted work., Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work.

Sonographic assessment of calcium pyrophosphate deposition disease at wrist. A focus on the dorsal scapho-lunate ligament

OBJECTIVES

To investigate the diagnostic accuracy of ultrasound and conventional radiography in the evaluation of calcium pyrophosphate crystal deposits at wrist level.

METHODS

Consecutive patients with a "definite" diagnosis of calcium pyrophosphate deposition disease and disease-controls were prospectively included in this cross-sectional single-centre study. Scapho-lunate ligament, triangular fibrocartilage complex, and volar recess of the radio-lunate joint were explored using ultrasound, conventional radiography and computed tomography.

RESULTS

Sixty one patients and 39 disease controls were enrolled. Two-hundred wrists were evaluated using both conventional radiography and ultrasound and 26 using computed tomography. Ultrasound findings indicative of crystal deposits were found in at least one wrist in 95.1% of patients and in 15.4% of controls (P<0.001). Scapho-lunate ligament calcifications were reported in 83.6% of patients and in 5.1% of controls (P<0.001). On conventional radiography, calcifications were found in at least one wrist in 72.1% of patients and in 0% of controls (P<0.001). Using the Ryan-McCarty criteria as a gold standard, sensitivity, specificity and diagnostic accuracy were 0.72 (0.59-0.83), 1.0 (0.91-1.0) and 0.83 (0.74-0.90) for conventional radiography and 0.95 (0.86-0.99), 0.85 (0.69-0.94) and 0.91 (0.84-0.96) for ultrasound. The agreement between ultrasound and computed tomography was substantial when assessing triangular fibrocartilage complex (kappa=0.70; 0.43-0.97) and scapho-lunate ligament (kappa=0.69; 0.41-0.97), and moderate for radio-lunate joint (kappa=0.46; 0.12-0.80).

CONCLUSIONS

This study supports the diagnostic accuracy of ultrasound in evaluating wrist involvement in calcium pyrophosphate deposition disease. The inclusion of the scapho-lunate ligament in a disease-oriented scanning protocol could improve the diagnostic performance of ultrasound.

How normal is the enthesis by ultrasound in healthy subjects?

OBJECTIVES

To explore the prevalence of the ultrasound (US) findings of enthesitis in a group of healthy subjects.

METHODS

US assessments of quadriceps, patellar and Achilles tendons, and plantar fascia entheses were performed by a rheumatologist on 82 healthy volunteers focusing on the US findings indicative of "active" inflammation according to the Outcome Measures in Rheumatology (OMERACT) definitions.

RESULTS

Eight hundred and twenty entheses were evaluated in 82 healthy subjects. One or more US findings of "active" inflammation were found in at least one enthesis in 30 out of 82 subjects (34.1%), in 69 out of 820 entheses (8.4%). Entheseal thickening, hypoechogenicity and PD signal were respectively found in at least one enthesis in 23 (28.0%), 11 (13.4%) and 8 (9.8%) out of 82 subjects. Among the 69 entheses showing US features of "active" inflammation, entheseal thickening, hypoechogenicity and PD signal were found as isolated in 61 entheses and in combination in the remaining 8 (entheseal thickening and hypoechogenicity).

CONCLUSIONS

Our results show a relatively high prevalence of US findings of "active" inflammation at the lower limb entheses in a group of healthy subjects, thus questioning the discriminant power of the OMERACT definitions for the diagnosis of "active" enthesitis. A combination of grey-scale and PD findings at a specific threshold to be defined could improve both the reliability and clinical usefulness of US.

Prevalence and distribution of cartilage damage at the metacarpal head level in rheumatoid arthritis and osteoarthritis: an ultrasound study

OBJECTIVES

To determine the prevalence and distribution of US-detected qualitative cartilage damage at metacarpal heads of patients with RA and hand OA.

METHODS

Fifty-two RA patients and 34 patients with hand OA were enrolled. US examination of the metacarpal head cartilage from the II to V finger of both hands was performed. A total of 414 MCP joints in RA and 266 MCP joints in OA patients were scanned with a linear probe up to 22 MHz. Qualitative assessments using a previously described scoring system for cartilage damage were performed. The prevalence and distribution of cartilage damage were analysed. Multivariate regression analysis was used to determine the predictive value of age, gender, BMI, disease duration and the presence of RF and anti-CCP antibodies for US-detected cartilage damage.

RESULTS

The metacarpal head cartilage was positive for cartilage damage in 35.7% (148/414) of MCP joints in RA and in 43.6% (116/266) of MCP joints in OA patients. In RA, the hyaline cartilage of the II and III metacarpal heads (bilaterally) was the most frequently affected. In OA, cartilage damage was more homogeneously distributed in all MCP joints. Multivariate regression analysis showed that age and disease duration, but not gender, BMI or autoantibody status, were independent predictors of US-detected cartilage damage in RA.

CONCLUSION

Cartilage damage was found in more than one-third of the MCP joints in both RA and OA patients, and in RA patients, the II and III MCP joints were the most damaged.