Validation and incorporation of digital entheses into a preliminary GLobal OMERACT Ultrasound DActylitis Score (GLOUDAS) in psoriatic arthritis

OBJECTIVES

The main objective was to generate a GLobal OMERACT Ultrasound DActylitis Score (GLOUDAS) in psoriatic arthritis and to test its reliability. To this end, we assessed the validity, feasibility and applicability of ultrasound assessment of finger entheses to incorporate them into the scoring system.

METHODS

The study consisted of a stepwise process. First, in cadaveric specimens, we identified enthesis sites of the fingers by ultrasound and gross anatomy, and then verified presence of entheseal tissue in histological samples. We then selected the entheses to be incorporated into a dactylitis scoring system through a Delphi consensus process among international experts. Next, we established and defined the ultrasound components of dactylitis and their scoring systems using Delphi methodology. Finally, we tested the interobserver and intraobserver reliability of the consensus- based scoring systemin patients with psoriatic dactylitis.

RESULTS

32 entheses were identified in cadaveric fingers. The presence of entheseal tissues was confirmed in all cadaveric samples. Of these, following the consensus process, 12 entheses were selected for inclusion in GLOUDAS. Ultrasound components of GLOUDAS agreed on through the Delphi process were synovitis, tenosynovitis, enthesitis, subcutaneous tissue inflammation and periextensor tendon inflammation. The scoring system for each component was also agreed on. Interobserver reliability was fair to good (κ 0.39-0.71) and intraobserver reliability good to excellent (κ 0.80-0.88) for dactylitis components. Interobserver and intraobserver agreement for the total B-mode and Doppler mode scores (sum of the scores of the individual abnormalities) were excellent (interobserver intraclass correlation coefficient (ICC) 0.98 for B-mode and 0.99 for Doppler mode; intraobserver ICC 0.98 for both modes).

CONCLUSIONS

We have produced a consensus-driven ultrasound dactylitis scoring system that has shown acceptable interobserver reliability and excellent intraobserver reliability. Through anatomical knowledge, small entheses of the fingers were identified and histologically validated.

Standardization of interstitial lung disease assessment by ultrasound: results from a Delphi process and web-reliability exercise by the OMERACT ultrasound working group

OBJECTIVES

Over the last years ultrasound has shown to be an important tool for evaluating lung involvement, including interstitial lung disease (ILD) a potentially severe systemic involvement in many rheumatic and musculoskeletal diseases (RMD). Despite the potential sensitivity of the technique the actual use is hampered by the lack of consensual definitions of elementary lesions to be assessed and of the scanning protocol to apply. Within the Outcome Measures in Rheumatology (OMERACT) Ultrasound Working Group we aimed at developing consensus-based definitions for ultrasound detected ILD findings in RMDs and assessing their reliability in dynamic images.

METHODS

Based on the results from a systematic literature review, several findings were identified for defining the presence of ILD by ultrasound (i.e., Am-lines, B-lines, pleural cysts and pleural line irregularity). Therefore, a Delphi survey was conducted among 23 experts in sonography to agree on which findings should be included and on their definitions. Subsequently, a web-reliability exercise was performed to test the reliability of the agreed definitions on video-clips, by using kappa statistics.

RESULTS

After three rounds of Delphi an agreement >75 % was obtained to include and define B-lines and pleural line irregularity as elementary lesions to assess. The reliability in the web-based exercise, consisting of 80 video-clips (30 for pleural line irregularity, 50 for B-lines), showed moderate inter-reader reliability for both B-lines (kappa = 0.51) and pleural line irregularity (kappa = 0.58), while intra-reader reliability was good for both B-lines (kappa = 0.72) and pleural line irregularity (kappa = 0.75).

CONCLUSION

Consensus-based ultrasound definitions for B-lines and pleural line irregularity were obtained, with moderate to good reliability to detect these lesions using video-clips. The next step will be testing the reliability in patients with ILD linked to RMDs and to propose a consensual and standardized protocol to scan such patients.

The Sjögren's Working Group: The 2023 OMERACT meeting and provisional domain generation

Sjögren's disease (SjD) is a systemic autoimmune exocrinopathy with key features of dryness, pain, and fatigue. SjD can affect any organ system with a variety of presentations across individuals. This heterogeneity is one of the major barriers for developing effective disease modifying treatments. Defining core disease domains comprising both specific clinical features and incorporating the patient experience is a critical first step to define this complex disease. The OMERACT SjD Working Group held its first international collaborative hybrid meeting in 2023, applying the OMERACT 2.2 filter toward identification of core domains. We accomplished our first goal, a scoping literature review that was presented at the Special Interest Group held in May 2023. Building on the domains identified in the scoping review, we uniquely deployed multidisciplinary experts as part of our collaborative team to generate a provisional domain list that captures SjD heterogeneity.

Artificial intelligence model for segmentation and severity scoring of osteophytes in hand osteoarthritis on ultrasound images

Objective

To develop an artificial intelligence (AI) model able to perform both segmentation of hand joint ultrasound images for osteophytes, bone, and synovium and perform osteophyte severity scoring following the EULAR-OMERACT grading system (EOGS) for hand osteoarthritis (OA).

Methods

One hundred sixty patients with pain or reduced function of the hands were included. Ultrasound images of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), distal interphalangeal (DIP), and first carpometacarpal (CMC1) joints were then manually segmented for bone, synovium and osteophytes and scored from 0 to 3 according to the EOGS for OA. Data was divided into a training, validation, and test set. The AI model was trained on the training data to perform bone, synovium, and osteophyte identification on the images. Based on the manually performed image segmentation, an AI was trained to classify the severity of osteophytes according to EOGS from 0 to 3. Percent Exact Agreement (PEA) and Percent Close Agreement (PCA) were assessed on individual joints and overall. PCA allows a difference of one EOGS grade between doctor assessment and AI.

Results

A total of 4615 ultrasound images were used for AI development and testing. The developed AI model scored on the test set for the MCP joints a PEA of 76% and PCA of 97%; for PIP, a PEA of 70% and PCA of 97%; for DIP, a PEA of 59% and PCA of 94%, and CMC a PEA of 50% and PCA of 82%. Combining all joints, we found a PEA between AI and doctor assessments of 68% and a PCA of 95%.

Conclusion

The developed AI model can perform joint ultrasound image segmentation and severity scoring of osteophytes, according to the EOGS. As proof of concept, this first version of the AI model is successful, as the agreement performance is slightly higher than previously found agreements between experts when assessing osteophytes on hand OA ultrasound images. The segmentation of the image makes the AI explainable to the doctor, who can immediately see why the AI applies a given score. Future validation in hand OA cohorts is necessary though.

Solid validity evidence for two tools assessing competences in musculoskeletal ultrasound: a validity study

OBJECTIVES

Musculoskeletal ultrasound (MSUS) is increasingly used by rheumatologists in daily clinical practice. However, MSUS is only valuable in trained hands, and assessment of trainee competences is therefore essential before independent practice. Thus, this study aimed to establish validity evidence for the EULAR and the Objective Structured Assessment of Ultrasound Skills (OSAUS) tools used for assessing MSUS competences.

METHODS

Thirty physicians with different levels of MSUS experience (novices, intermediates, and experienced) performed four MSUS examinations of different joint areas on the same rheumatoid arthritis patient. All examinations were video recorded (n = 120), anonymized, and subsequently assessed in random order by two blinded raters using first the OSAUS assessment tool followed by the EULAR tool 1 month after.

RESULTS

The inter-rater reliability between the two raters was high for both the OSAUS and EULAR tools, with a Pearson correlation coefficient (PCC) of 0.807 and 0.848, respectively. Both tools demonstrated excellent inter-case reliability, with a Cronbach's alpha of 0.970 for OSAUS and 0.964 for EULAR. Furthermore, there was a strong linear correlation between the OSAUS and the EULAR performance scores and the participants' experience levels (R2 = 0.897 and R2 = 0.868, respectively) and a significant discrimination between different MSUS experience levels (P < 0.001 for both).

CONCLUSIONS

MSUS operator competences can be assessed reliably and valid using either the OSAUS or the EULAR assessment tool, thereby allowing a uniform competency-based MSUS education in the future. Although both tools demonstrated high inter-rater reliability, the EULAR tool was superior to OSAUS.

TRIAL REGISTRATION

ClinicalTrials.gov, http://clinicaltrials.gov, NCT05256355.

The Novel OMERACT Ultrasound Scoring System for Salivary Gland Changes in Patients With Sjögren Syndrome Is Associated With MRI and Salivary Flow Rates

OBJECTIVE

To assess the construct validity of the novel Outcome Measures in Rheumatology (OMERACT) ultrasound (US) semiquantitative scoring system for morphological lesions in major salivary glands by comparing it with magnetic resonance imaging (MRI) and unstimulated whole salivary flow rates (U-WSFRs) in patients with primary Sjögren syndrome (pSS).

METHODS

Nine sonographers applied the OMERACT 0-3 grayscale scoring system for parotid (PGs) and submandibular glands (SMGs) in 11 patients with pSS who also had MRIs performed. These were evaluated by 2 radiologists using a semiquantitative 0-3 scoring system for morphological lesions. The agreement between US and MRI and the association between U-WSFRs and imaging structural lesions was determined. A score ≥ 2 for both US and MRI was defined as gland pathology.

RESULTS

The prevalence of US morphological lesions in 11 patients with a score ≥ 2 was 58% for PGs and 76% for SMGs, and 46% and 41% for PGs and SMGs, respectively, for MRI. The agreement between OMERACT US scores and MRI scores was 73-91% (median 82%) in the right PG and 73-91% (median 91%) in the left PG, 55-91% (median 55%) in the right SMG and 55-82% (median 55%) in the left SMG. When relations between the presence of hyposalivation and an US score ≥ 2 were examined, agreement was 91-100% (median 83%) in both PGs and 55-91% (median 67%) in both SMGs.

CONCLUSION

There is moderate to strong agreement between the OMERACT US and MRI scores for major salivary glands in patients with pSS. Similar agreement ratios were observed between the higher OMERACT US scores and presence of hyposalivation.

Low incidence of malignancy in patients with suspected polymyalgia rheumatica or giant cell arteritis, examined with FDG-PET/CT

Introduction

The need to systematically examine patients suspected of polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) for malignancy is controversial. The aim of this study was to assess the frequency of malignancy in patients with suspected PMR and/or GCA who have been referred to a 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography with computed tomography (FDG-PET/CT) as part of the diagnostic investigation.

Method

The records of all patients referred to FDG-PET/CT from Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup with the suspicion of PMR and/or GCA during a two-year period, were retrospectively reviewed. Data was analyzed with descriptive statistics, and a standard incidence ratio was calculated based on background cancer incidences extracted from the NORDCAN database.

Results

220 patients were included in the study. Findings suspicious of malignancy were found in 19 of the examinations, and in seven cases (3.2%), malignancy was confirmed. In three out of the seven cases the patients were diagnosed with PMR concomitantly with malignancy. The estimated standardized incidence ratio (SIR) for cancer compared to the background incidence of cancer in Denmark was 1.58 (95% CI 0.63-2.97), i.e., not statistically significant. There were no statistically significant differences in characteristics of the patients that were diagnosed with malignancy compared with those that were not.

Conclusion

The frequency of malignancy in this cohort of patients with suspected PMR/GCA who underwent PET/CT was low. Our results, though based on a small cohort, do not suggest that all patients with suspected PMR/GCA should systematically be examined with FDG-PET/CT for excluding malignancy.

Peripheral joint and enthesis involvement in patients with newly diagnosed inflammatory bowel disease: symptoms, clinical and ultrasound findings - a population-based cohort study

OBJECTIVES

Musculoskeletal manifestations in patients with inflammatory bowel disease (IBD) are common and associated with poorer outcomes. Hence, early detection is important to optimally tailor treatment. We aimed to determine the prevalence and distribution of inflammatory lesions in peripheral joints and entheses in newly diagnosed IBD patients.

DESIGN

Patients with newly diagnosed IBD from a prospective population-based inception cohort were consecutively included. Data on musculoskeletal symptoms were collected by questionnaires and by structured rheumatological interview. Peripheral joints and entheses were assessed clinically and by ultrasound (US), using standardized definitions.

RESULTS

Of 110 included patients (mean age: 42 years, 40% male, 70 with ulcerative colitis (UC), 40 with Crohn's disease (CD)), history of ≥1 musculoskeletal symptoms was reported by 49%. Clinical examination revealed peripheral musculoskeletal manifestations in 56 (52.3%) patients; 29 (27.1%) had ≥1 tender and/or swollen joints and 49 (45.8%) ≥1 tender entheses. Small peripheral joints were predominantly affected. US found inflammation in ≥1 joint or enthesis in 52 (49.5 %) patients; 29 (27.4 %) had US synovitis in ≥1 joint, while 36 (34%) US enthesitis. Fibromyalgia classification criteria were fulfilled in seven (7.9%) patients. There was no difference in clinical or US findings between patients with UC and CD, nor between patients with active and inactive IBD.

CONCLUSION

Half of patients with newly diagnosed IBD had inflammation in their peripheral joints and/or entheses, documented by rheumatological clinical and ultrasound evaluations. This indicates a need for multidisciplinary collaboration to ensure an optimal therapeutic strategy for suppressing inflammation in all disease domains.

A quantitative and site-specific atlas of the citrullinome reveals widespread existence of citrullination and insights into PADI4 substrates

Despite the importance of citrullination in physiology and disease, global identification of citrullinated proteins, and the precise targeted sites, has remained challenging. Here we employed quantitative-mass-spectrometry-based proteomics to generate a comprehensive atlas of citrullination sites within the HL60 leukemia cell line following differentiation into neutrophil-like cells. We identified 14,056 citrullination sites within 4,008 proteins and quantified their regulation upon inhibition of the citrullinating enzyme PADI4. With this resource, we provide quantitative and site-specific information on thousands of PADI4 substrates, including signature histone marks and transcriptional regulators. Additionally, using peptide microarrays, we demonstrate the potential clinical relevance of certain identified sites, through distinct reactivities of antibodies contained in synovial fluid from anti-CCP-positive and anti-CCP-negative people with rheumatoid arthritis. Collectively, we describe the human citrullinome at a systems-wide level, provide a resource for understanding citrullination at the mechanistic level and link the identified targeted sites to rheumatoid arthritis.

Development and validation of a new tool for assessment of trainees' interventional musculoskeletal ultrasound skills

OBJECTIVES

Interventional musculoskeletal ultrasound (MSUS) procedures are routinely performed in rheumatology practice. However, the efficacy and safety of the procedures rely on the competence of the physician, and assessment of skills is crucial. Thus, this study aimed to develop and establish validity evidence for a tool assessing trainees' interventional MSUS skills.

METHODS

An expert panel of rheumatologists modified an existing tool for assessing competences in invasive abdominal and thoracic ultrasound procedures. The new tool (the Assessment of Interventional Musculoskeletal Ultrasound Skills (AIMUS) tool) reflects the essential steps in interventional MSUS. To establish validity evidence, physicians with different levels of interventional MSUS experience were enrolled and performed two procedures on a rubber fantom, simulating real patient cases. All performances were video recorded, anonymized, and assessed in random order by two blinded raters using the AIMUS tool.

RESULTS

Sixty-five physicians from 21 different countries were included and categorized into groups based on their experience, resulting in 130 videos for analysis. The internal consistency of the tool was excellent, with a Cronbach's alpha of 0.96. The inter-case reliability was good with a Pearson's correlation coefficient (PCC) of 0.74 and the inter-rater reliability was moderate to good (PCC 0.58). The ability to discriminate between different levels of experience was highly significant (p< 0.001).

CONCLUSIONS

We have developed and established validity evidence for a new interventional MSUS assessment tool. The tool can be applied in future competency-based educational programs, provide structured feedback to trainees in daily clinical practice, and ensure end-of-training competence.

Allogeneic mesenchymal stem cell therapy for dry eye disease in patients with Sjögren's syndrome: A randomized clinical trial

PURPOSE

This double-blinded randomized clinical trial aimed to evaluate the efficacy of injecting allogeneic adipose-derived mesenchymal stem cells (ASCs) into the lacrimal gland (LG) for the treatment of dry eye disease (DED) secondary to Sjögren's syndrome (SS).

METHODS

Fifty-four participants with severe DED secondary to SS were included and allocated to either ASCs (n = 20), vehicle (n = 20), or a non-randomized observation group (n = 14). The intervention groups received a single injection of either ASCs or an active comparator (vehicle, Cryostor® CS10) into the LG in one eye, while the observation group received lubricating eye drops only. The primary outcome measure was changes in Ocular Surface Disease Index (OSDI) score and secondary outcome measures were non-invasive tear break-up time, tear meniscus height, Schirmer's test, and Oxford score within a 12-month follow-up.

RESULTS

A significant reduction in OSDI score was observed in the ASCs and vehicle groups compared to the observation group. In addition, the ASCs group demonstrated a significant increase in non-invasive tear break-up time compared to the vehicle group at the 4-week follow-up and to the observation group at the 12-month follow-up. A significant improvement in ocular surface staining, tear osmolarity, and Schirmer test score from baseline was also observed in the ASCs group; however, these changes were not significant compared to the other groups.

CONCLUSION

Improvement of subjective and objective signs and symptoms of DED was observed in both intervention groups following injection into the LG compared to the observation group. Future studies should investigate the mode-of-action of both injection treatments.

Multimodality Imaging in Cranial Giant Cell Arteritis: First Experience with High-Resolution T1-Weighted 3D Black Blood without Contrast Enhancement Magnetic Resonance Imaging

In order to support or refute the clinical suspicion of cranial giant cell arteritis (GCA), a supplemental imaging modality is often required. High-resolution black blood Magnetic Resonance Imaging (BB MRI) techniques with contrast enhancement can visualize artery wall inflammation in GCA. We compared findings on BB MRI without contrast enhancement with findings on 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/low-dose computed tomography (2-[18F]FDG PET/CT) in ten patients suspected of having GCA and in five control subjects who had a 2-[18F]FDG PET/CT performed as a routine control for malignant melanoma. BB MRI was consistent with 2-[18F]FDG PET/CT in 10 out of 10 cases in the group with suspected GCA. In four out of five cases in the control group, the BB MRI was consistent with 2-[18F]FDG PET/CT. In this small population, BB MRI without contrast enhancement shows promising performance in the diagnosis of GCA, and might be an applicable imaging modality in patients.

The impact of an ultrasound atlas for scoring salivary glands in primary Sjögren's syndrome: a pilot study

The objective of this pilot study was to assess the impact of a salivary gland ultrasound (SGUS) atlas for scoring parenchymal changes in Sjögren's syndrome by assessing the reliability of the scoring system (0-3), without and with the use of the SGUS atlas. Ten participants with varying experience in SGUS contributed to the reliability exercise. Thirty SGUS images of the submandibular and parotid gland with abnormalities ranging from 0 to 3 were scored using the written definitions of the OMERACT SGUS scoring system and using the SGUS atlas based on the OMERACT scoring system. For intra-reader reliability, two rounds were performed without and with the atlas-in the 2nd round the 30 images were rearranged in random order by a physician not included in the scoring. Inter-reader reliability was also determined in both rounds. Without using the atlas, the SGUS OMERACT scoring system showed fair inter-reader reliability in round 1 (mean kappa 0.36; range 0.06-0.69) and moderate intra-reader reliability (mean kappa 0.55; range 0.28-0.81). With the atlas, inter-reader reliability improved in round 1 to moderate (mean kappa 0.52; range 0.31-0.77) and intra-reader reliability to good (mean kappa 0.69; range 0.46-0.86). Higher intra-reader reliability was noted in participants with previous SGUS experience. The SGUS atlas increased both intra- and inter-reader reliability for scoring gland pathology in participants with varying SGUS experience suggesting a possible future role in clinical practice and trials. Key Points • Ultrasonography can detect parenchymal changes in salivary glands in patients with Sjögren's disease. • An ultrasound atlas may improve reliability of scoring parenchymal changes in salivary glands.

E-learning and practical performance in musculoskeletal ultrasound: a multicentre randomized study

OBJECTIVES

To examine the effect of pre-course e-learning on residents' practical performance in musculoskeletal ultrasound (MSUS).

METHODS

This was a multicentre, randomized controlled study following the Consolidated Standards of Reporting Trials (CONSORT) statement. Residents with no or little MSUS experience were randomized to either an e-learning group or a traditional group. One week before a 2-day face-to-face MSUS course, the e-learning group received access to an interactive platform consisting of online lectures, assignments, and practical instruction videos aligned with the content of the course. The traditional group only received standard pre-course information (program, venue, and time). All participants performed a pre- and post-course practical MSUS examination and were assessed by two individual raters, blinded to the group allocation, using the validated Objective Structured Assessment of Ultrasound Skills (OSAUS) tool.

RESULTS

Twenty-eight participants completed the study. There were no statistically significant differences in the pre- or post-course practical MSUS performance between the e-learning group and the traditional group; the mean pre-course OSAUS score (s.d.) in the -learning group was 5.4 (3.7) compared with 5.2 (2.4) in the traditional group (P = 0.8), whereas the post-course OSAUS score in the e-learning group was 11.1 (2.8) compared with 10.9 (2.4) in the traditional group (P = 0.8). There was a significant difference between the mean pre- and post-course scores (5.74 points, P < 0.001). The OSAUS assessment tool demonstrated good inter-rater reliability (intra-class correlation = 0.84).

CONCLUSION

We found no significant impact of pre-course e-learning on novices' acquisition of practical MSUS skills. Hands-on training is of the utmost importance and improves MSUS performance significantly. The OSAUS assessment tool is an applicable tool with high interrater reliability.

TRIAL REGISTRATION

https://clinicaltrials.gov/ NCT04959162.

Development and validation of an OMERACT ultrasound scoring system for the extent of calcium pyrophosphate crystal deposition at the joint level and patient level

BACKGROUND

The Calcium Pyrophosphate Deposition (CPPD) subgroup of the Outcome Measures in Rheumatology (OMERACT) Ultrasound working group was established to validate ultrasound as an outcome measure instrument for CPPD, and in 2017 has developed and validated standardised definitions for elementary lesions for the detection of calcium pyrophosphate crystals in joints. The aim of this study was to develop and evaluate the reliability of a consensus-based ultrasound scoring system for CPPD extent, representing the next phase in the OMERACT methodology.

METHODS

In this study the novel scoring system for CPPD was developed through a stepwise process, following an established OMERACT ultrasound methodology. Following a previous systematic review to gather available evidence on existing scoring systems for CPPD, the novel scoring system was developed through a Delphi survey based on the expert opinion of the members of the OMERACT Ultrasound working group-CPPD subgroup. The reliability of the scoring system was then tested on a web-based and patient-based exercise. Intra-reader and inter-reader reliability of the new scoring system was assessed using weighted Light's κ coefficients.

FINDINGS

The four-grade semiquantitative scoring system consisted of: grade 0 (no findings consistent with CPPD), grade 1 (≤3 single spots or 1 small deposit), grade 2 (>3 single spots or >1 small deposit or ≥1 larger deposit occupying ≤50% of the structure under examination in the reference image-ie, the scanning view with the highest grade of depositions), and grade 3 (deposits that occupy more than 50% of the structure under examination in the reference image). The score should be applied to the knee (menisci and hyaline cartilage) and the triangular fibrocartilage complex of the wrist. The intra-reader and inter-reader reliabilities on static images were almost perfect (κ 0·90 [95% CI 0·79-1·00] and κ 0·84 [0·79-0·88]), and on the eight patients recruited (four [50%] female and four [50%] male) were substantial (κ 0·72 [95% CI 0·47 to 0·96] and 0·66 [0·61 to 0·71]).

INTERPRETATION

This OMERACT ultrasound scoring system for CPPD was reliable on both static images and patients. The scoring system might be a valuable tool for ensuring valid and comparable results in clinical trials and could help monitor the extent of crystal deposition in patients with CPPD in clinical practice.

FUNDING

The Italian Ministry of Health - Ricerca Corrente.

Colchicine twice a day for hand osteoarthritis (COLOR): a double-blind, randomised, placebo-controlled trial

BACKGROUND

Colchicine has been suggested for osteoarthritis treatment, but evidence is contradictory. We aimed to investigate colchicine's efficacy and safety compared with placebo in people with hand osteoarthritis.

METHODS

In this single-centre, double-blind, randomised, placebo-controlled trial we recruited adults with symptomatic hand osteoarthritis and finger pain of at least 40 mm on a 100 mm visual analogue scale from an outpatient clinic in Denmark. The hand with the most severe finger pain at inclusion was the target hand. Participants were randomly assigned (1:1) to 0·5 mg colchicine or placebo taken orally twice a day for 12 weeks, stratified by BMI (≥30 kg/m2), sex, and age (≥75 years). Participants, outcome assessors, and data analysts were masked to treatment allocation. The primary endpoint was change from baseline to week 12 in target hand finger pain, assessed on a 100 mm visual analogue scale with a pre-specified minimal clinically important difference of 15 mm, in the intention-to-treat population. Safety was assessed at week 12 in the intention-to-treat population. The study was registered with ClinicalTrials.gov, NCT04601883, and with EudraCT, 2020-002803-20.

FINDINGS

Between Jan 15, 2021, and March 3, 2022, 186 people were screened for eligibility, and 100 were randomly assigned to receive colchicine (n=50) or placebo (n=50). Participants had a mean age of 70·9 (SD 7·5) years, 69 (69%) of 100 were women and 31 (31%) were men. All participants completed the study. The mean change from baseline to week 12 in finger pain were -13·9 mm (SE 2·8) in the colchicine group and -13·5 mm (2·8) in the placebo group, with a between-group difference (colchicine vs placebo) of -0·4 mm (95% CI -7·6 to 6·7; p=0·90). In the colchicine group, there were 76 adverse events in 36 (72%) of 50 participants and one serious adverse advent (migraine attack leading to hospital admission). In the placebo group, there were 42 adverse events in 22 (44%) of 50 participants and two serious adverse events (cholecystitis and elevated alanine aminotransferase concentrations, in the same patient).

INTERPRETATION

In people with painful hand osteoarthritis, treatment with 0·5 mg of colchicine twice day for 12 weeks did not effectively relieve pain, and treatment with colchicine was associated with more adverse events.

FUNDING

The Oak Foundation, IMK Almene Fond, Minister Erna Hamilton's Scholarship for Science and Art, AP Moller and Wife Chastine McKinney Moller's Foundation for Medical Science Advancement, The Danish Medical Association, the Velux Foundation, Aase and Ejnar Danielsen's Foundation, and Director Emil C Hertz and Wife Inger Hertz's foundation.

The provisional OMERACT ultrasonography score for giant cell arteritis

OBJECTIVES

To develop an Outcome Measures in Rheumatology (OMERACT) ultrasonography score for monitoring disease activity in giant cell arteritis (GCA) and evaluate its metric properties.

METHODS

The OMERACT Instrument Selection Algorithm was followed. Forty-nine members of the OMERACT ultrasonography large vessel vasculitis working group were invited to seven Delphi rounds. An online reliability exercise was conducted using images of bilateral common temporal arteries, parietal and frontal branches as well as axillary arteries from 16 patients with GCA and 7 controls. Sensitivity to change and convergent construct validity were tested using data from a prospective cohort of patients with new GCA in which ultrasound-based intima-media thickness (IMT) measurements were conducted at weeks 1, 3, 6, 12 and 24.

RESULTS

Agreement was obtained (92.7%) for the OMERACT GCA Ultrasonography Score (OGUS), calculated as follows: sum of IMT measured in every segment divided by the rounded cut-off values of IMTs in each segment. The resulting value is then divided by the number of segments available. Thirty-five members conducted the reliability exercise, the interrater intraclass correlation coefficient (ICC) for the OGUS was 0.72-0.84 and the median intrareader ICC was 0.91. The prospective cohort consisted of 52 patients. Sensitivity to change between baseline and each follow-up visit up to week 24 yielded standardised mean differences from -1.19 to -2.16, corresponding to large and very large magnitudes of change, respectively. OGUS correlated moderately with erythrocyte sedimentation rate, C reactive protein and Birmingham Vasculitis Activity Score (corrcoeff 0.37-0.48).

CONCLUSION

We developed a provisional OGUS for potential use in clinical trials.

Ultrasound-Guided Transcutaneous Injection in the Lacrimal Gland: A Description of Sonoanatomy and Technique

Purpose: To develop a method of injecting a volume up to 50% of the lacrimal gland (LG) volume while minimizing patient discomfort and maximizing accurate drug delivery. Herein we describe a series of ultrasound (US)-guided transcutaneous injections in the LG and discuss the safety and feasibility of this technique. Methods: Ultrasonography was performed in 40 patients with aqueous deficient dry eye disease using a GE Logic E10 (Milwaukee, Wisconsin, USA) US machine with a 6-24 MHz transducer. US was performed by 2 medical experts in ultrasonography. We recorded the injection and observed an enlargement of the LG ensuring delivery within the LG before the needle was removed. Assessment of injection-related adverse event was performed immediately after the injection. Results: The position of the injection needle within the LG was documented in all 40 patients. Injection of the stem cells and vehicle (N = 20) or solely vehicle (N = 20) led to an enlargement of the glandular structures in all cases. No serious adverse reactions related to the injections were observed. Conclusion: US-guided injection into the LG enables injection on a closed eye causing minimum patient discomfort and maximum certainty of accurate drug delivery. US can provide real-time images and may be used to safely guide the needle ensuring correct placement and injection within the gland capsule. This reduces the risk of injury to the eye and adjacent structures and makes a precise transcutaneous injection possible. Clinical Trial Registration number: NCT04615455.

Which are the most frequently involved peripheral joints in calcium pyrophosphate crystal deposition at imaging? A systematic literature review and meta-analysis by the OMERACT ultrasound – CPPD subgroup

Objectives

To identify the prevalence of calcium pyrophosphate crystal deposition (CPPD) using ultrasound and conventional radiology at peripheral joints in patients with suspected or definite CPPD.

Methods

A systematic literature search was performed in PubMed and Embase using pre-defined search strategies from inception to April 2021 to identify studies that evaluated conventional radiology and ultrasound in detecting CPPD at peripheral joints, including definite or suspected CPPD [Research question 1 (RQ1) and Research Question 2 (RQ2), respectively]. For the meta-analysis, the first, second, and third sub-analysis included studies with the knee, and knee or wrist as the index joint for CPPD (without restrictions on the reference standard) and synovial fluid analysis or histology as a reference standard (without restrictions on the index joint), respectively.

Results

One-thousand eight hundred and twenty-seven manuscripts were identified, of which 94 articles were finally included. Twenty-two and seventy-two papers were included in RQ1 and RQ2, respectively. The knee had the highest prevalence for RQ1 and RQ2 by both conventional radiology and ultrasound, followed by the wrist with the highest prevalence for RQ1. The hand had the lowest CPPD prevalence. The third sub-analysis showed a higher CPPD prevalence on ultrasound than conventional radiology at the knee (only data available).

Conclusion

Among all peripheral joints, the knees and wrists could be regarded as the target joints for CPPD detection by imaging. Furthermore, ultrasound seems to detect a higher number of calcium pyrophosphate deposits than conventional radiology, even when using a more restrictive reference standard.

Lacrimal and salivary gland ultrasound - how and when to use in patients with primary Sjögren's syndrome

This paper addresses how to perform an ultrasound assessment of the salivary and lacrimal glands, how to identify pathological changes, and how to score disease activity, focusing on the use for primary Sjögren's syndrome (pSS). It addresses the role of salivary gland ultrasound for diagnosing and management of patients with pSS and touches upon the use for differential diagnosis, including how and when to perform ultrasound-guided biopsies and injections.

Comparison of temporal artery ultrasound versus biopsy in the diagnosis of giant cell arteritis

BACKGROUND/OBJECTIVES

Giant cell arteritis (GCA) is a medical and ophthalmological emergency due to risk of stroke and sudden irreversible loss of vision. Fast and accurate diagnosis is important to prevent complications and long-term high dose glucocorticoids toxicity. Temporal artery biopsy is gold standard for diagnosing GCA. However, temporal artery ultrasound is a fast and non-invasive procedure which may provide a supplement or an alternative to biopsy. This study assesses the diagnostic performance of ultrasound and biopsy in the diagnosis of GCA.

SUBJECTS/METHODS

Examination results of patients suspected of having GCA in the period from August 2018 to June 2019 were reviewed. Patients underwent clinical examination and blood tests. Within a few days of starting glucocorticoid treatment, temporal ultrasound and unilateral biopsy were performed. Experienced physicians established the final clinical diagnosis at 6-months follow-up.

RESULTS

Seventy-eight patients underwent both ultrasound and biopsy. Thirty-five (45%) received the final clinical diagnosis of GCA. Compared with the final clinical diagnosis, biopsy had a sensitivity of 69% (51-83%) and a specificity of 100% (92-100%), and ultrasound a sensitivity of 63% (45-79%) and a specificity of 79% (64-94%). Area under the receiver operating characteristics curves were 0.84 and 0.71 for biopsy and ultrasound respectively (p = 0.048). False negative rate of ultrasound was 4 out of 78 (5%).

CONCLUSION

Sensitivity of ultrasound is almost on par with that of biopsy although the overall diagnostic accuracy of ultrasound was slightly lower. We find that ultrasound is a reliable tool for first line diagnosis of GCA.

Ultrasound assessment of degenerative muscle sarcopenia: the University of Barcelona ultrasound scoring system for sarcopenia

AIM

This study aimed to (1) determine the intraobserver and interobserver reliability of ultrasonographic measurement of muscle thickness (MT) and cross-sectional area (CSA) of the rectus femoris and biceps brachii, correlating these values with manual measurements on dissected cadavers and (2) develop the first semiquantitative musculoskeletal ultrasound (MSUS) scoring system of muscle morphology in sarcopenia and assess its intraobserver and interobserver reliability. In addition, the MSUS morphology score was compared with the corresponding histological images to verify concurrent validity.

METHODS

Ten cryopreserved limbs of 10 cadavers aged 68-91 years were evaluated. The MSUS scoring system was based on the severity of muscle degeneration on a 3-point qualitative scale: grade 1 (normal), grade 2 (moderate changes) and grade 3 (severe changes). Reliability was assessed with intraclass correlation coefficient (ICC) for the MT and CSA and with Cohen's kappa coefficients (κ) for the MSUS scoring system. Concurrent validity was analysed with ICC.

RESULTS

The results showed excellent intraobserver and interobserver reliability for both the MSUS evaluation of MT and CSA (ICC ≥0.93). The MSUS scoring system showed excellent intraobserver reliability (κ=1.0) and very good interobserver reliability (κ=0.85). There was also a high intra- and inter-observer reliability for the histological scorings (ĸ ≥0.85 and mean ĸ=0.70, respectively), as well as high reliability between the histology and MSUS scoring systems (ICC=0.92). All results were statistically significant (p≤0.001).

CONCLUSION

MSUS measures of MT and CSA and the novel MSUS scoring system for degenerative muscle changes in sarcopenia was found to be reliable and strongly associated with histological findings.

Flare during tapering of biological DMARDs in patients with rheumatoid arthritis in routine care: characteristics and predictors

OBJECTIVE

To identify predictors of flare in a 2-year follow-up study of patients with rheumatoid arthritis (RA) in sustained clinical remission tapering towards withdrawal of biological disease-modifying anti-rheumatic drugs (bDMARDs).

METHODS

Sustained clinical remission was defined as Disease Activity Score for 28 joints (DAS28)-C reactive protein (CRP) ≤2.6 without radiographic progression for >1 year. bDMARDs were tapered according to a mandatory clinical guideline to two-thirds of standard dose at baseline, half of dose at week 16 and discontinuation at week 32. Prospective assessments for 2 years included clinical evaluation, conventional radiography, ultrasound and MRI for signs of inflammation and bone changes. Flare was defined as DAS28-CRP ≥2.6 with ∆DAS28-CRP ≥1.2 from baseline. Baseline predictors of flare were assessed by logistic regression analyses.

RESULTS

Of 142 included patients, 121 (85%) flared during follow-up of which 86% regained remission within 24 weeks after flare. Patients that flared were more often rheumatoid factor positive, had tried more bDMARDs and had higher baseline ultrasound synovitis sum scores than those not flaring. For patients on standard dose, predictors of flare within 16 weeks after reduction to two-thirds of standard dose were baseline MRI-osteitis (OR 1.16; 95% CI 1.03 to 1.33; p=0.014), gender (female) (OR 6.71; 95% CI 1.68 to 46.12; p=0.005) and disease duration (OR 1.06; 95% CI 1.01 to 1.11; p=0.020). Baseline predictors for flare within 2 years were ultrasound grey scale synovitis sum score (OR 1.19; 95% CI 1.02 to 1.44; p=0.020) and number of previous bDMARDs (OR 4.07; 95% CI 1.35 to 24.72; p=0.007).

CONCLUSION

The majority of real-world patients with RA tapering bDMARDs flared during tapering, with the majority regaining remission after stepwise dose increase. Demographic and imaging parameters (MR-osteitis/ultrasound greyscale synovitis) were independent predictors of immediate flare and flare overall and may be of importance for clinical decision-making in patients eligible for tapering.

Salivary gland ultrasound is associated with the presence of autoantibodies in patients with Sjögren's syndrome: A Danish single-centre study

OBJECTIVES

To investigate whether ultrasound findings of major salivary glands are correlated with serological markers, autoantibodies, patient- or doctor-reported disease activity in a Danish cohort of patients with primary Sjögren's Syndrome (pSS).

METHODS

In all, 49 patients at Odense University Hospital with pSS diagnosed according to the 2002 American-European Consensus Group (AECG) classification criteria were included. Patients were characterized using the EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI, score of systemic complications) and EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI), serologic markers, Schirmer's test and salivary test. Salivary gland ultrasound (SGUS) was performed of the submandibular and parotid glands and scored according to the Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) semi-quantitative scoring system.

RESULTS

More patients with abnormal SGUS had antinuclear antibodies (ANA) (p = 0.002), anti-Ro52 (p = 0.001), anti-Ro60 (p<0.001), anti-La (p<0.001) and IgM-RF (p<0.001). Titers for ANA (p = 0.02) and anti-Ro52 (p = 0.03) were higher in patients with abnormal SGUS. Twenty-three of the pSS patients had no pathological findings on SGUS. There was no correlation between SGUS severity and ESSDAI- or ESSPRI-scores.

CONCLUSIONS

Abnormal SGUS findings are associated with autoantibodies of high specificity for pSS but not with ESSDAI, ESSPRI or inflammatory markers.

Optimizing the anti-inflammatory strategies in (osteo)arthritis: local or systemic?

Arthritis is affecting millions of people globally, involvement and distribution depending on the type of arthritis. The most common arthritic conditions are osteoarthritis (OA) and rheumatoid arthritis (RA). Despite the pathogeneses being fundamentally different, both joint diseases share the same need for local treatment of synovitis. No current treatment can stop the progression of OA. Local articulate treatment including glucocorticoid (GC) injections, radiosynoviorthesis (RSO) and surgical synovectomy are the only options to relieve pain and temporally improve movability before surgical intervention. For RA, despite effective systemic treatments, similarly need for local articulate treatment is still present, especially early in the disease, but also in case of recurrent episodes of disease flare. Current evidence supports local GC injection as first line treatment for persistent synovitis in a single or a few joints. RSO provides an evident and effective alternative for GC refractory synovitis, especially in early RA. Surgical synovectomy is an invasive alternative, but with less documented efficacy. Whether one unsuccessful intraarticular GC injection is enough to change of mode of action for local treatment is still unclear and needs to be further investigated. In conclusion persistent single joint synovitis in OA and RA is well treated with local treatment. Intra-articular GC injection is considered as first line of treatment, but RSO provides an additional treatment alternative with less side effects and better evidence of efficacy than surgical synovectomy.

Ultrasonography of Inflammatory and Structural Lesions in Hand Osteoarthritis: An Outcome Measures in Rheumatology Agreement and Reliability Study

OBJECTIVE

To standardize and assess the reliability of ultrasonographic assessment of inflammatory and structural lesions in patients with hand osteoarthritis (OA).

METHODS

The Outcome Measures in Rheumatology Ultrasound Working Group selected synovial hypertrophy (SH), joint effusion (JE), and power Doppler (PD) signals as the main inflammatory lesions in hand OA, and suggested osteophytes in the scapho-trapezio-trapezoid (STT) and cartilage defects in the proximal interphalangeal (PIP) joints as novel additions to previous structural scoring systems. A complementary imaging atlas provided detailed examples of the scores. A reliability exercise of static images was performed for the inflammatory features, followed by a patient-based exercise with 6 sonographers testing inflammatory and structural features in 12 hand OA patients. We used Cohen's kappa for intrareader and Light's kappa for interreader reliability for all features except PD, in which prevalence-adjusted bias-adjusted kappa (PABAK) was applied. Percentage agreement was also assessed.

RESULTS

The web-based reliability exercise demonstrated substantial intra- and interreader reliability for all inflammatory features (κ > 0.64). In the patient-based exercise, intra- and interreader reliability, respectively, varied: SH κ = 0.73 and 0.45; JE κ = 0.70 and 0.55; PD PABAK = 0.90 and 0.88; PIP joint cartilage κ = 0.56 and 0.45; and STT osteophytes κ = 0.62 and 0.36. Percentage close agreement was high for all features (>85%).

CONCLUSION

With ultrasound, substantial to excellent intrareader reliability was found for inflammatory features of hand OA. Interreader reliability was moderate, but overall high close agreement between readers suggests that better reliability is achievable after further training. Assessment of osteophytes in the STT joint and cartilage in the PIP joints achieved less reliability and the latter is not endorsed.

Retrospective longitudinal assessment of ultrasound gout lesions using the OMERACT semi-quantitative scoring system

OBJECTIVES

The objectives of this study were (i) to evaluate the responsiveness of gout-specific US lesions representing urate deposition in patients receiving treat-to-target urate-lowering therapy using a binary and the OMERACT-defined semi-quantitative scoring systems; (ii) to determine the most responsive US measure for urate deposition and the optimal joint/tendon set for monitoring this.

METHODS

US (28 joints, 14 tendons) was performed in microscopically verified gout patients initiating/increasing urate-lowering therapy and repeated after 6 and 12 months. Static images/videos of pathologies were stored and scored binarily and semi-quantitatively for tophus, double contour sign (DC) and aggregates. Lesion scores were calculated at patient level, as were combined crystal sum scores. Responsiveness of lesions-scored binarily and semi-quantitatively-was calculated at both patient and joint/tendon levels.

RESULTS

Sixty-three patients underwent longitudinal evaluation. The static images/videos assessed retrospectively showed statistically significant decreases in tophus and DC, when scored binarily and semi-quantitatively, whereas aggregates were almost unchanged during follow-up. The responsiveness of the semi-quantitative tophus and DC sum scores were markedly higher than when using binary scoring. The most responsive measure for urate deposition was a combined semi-quantitative tophus-DC-sum score. A feasible joint/tendon set for monitoring included knee and first-second MTP joints and peroneus and distal patella tendons (all bilateral), representing the most prevalent and responsive sites.

CONCLUSION

The OMERACT consensus-based semi-quantitative US gout scoring system showed longitudinal validity with both tophus and DC being highly responsive to treatment when assessed in static images/videos. A responsive US measure for urate deposition and a feasible joint/tendon set for monitoring were proposed and may prove valuable in future longitudinal studies.

Nationwide, large-scale implementation of an online system for remote entry of patient-reported outcomes in rheumatology: characteristics of users and non-users and time to first entry

Aims

In May 2020, a nationwide, web-based system for remote entry of patient-reported outcomes (PROs) in inflammatory rheumatic diseases was launched and implemented in routine care (DANBIO-from-home). After 1.5 years of use, we explored clinical characteristics of patients who did versus did not use the system, and the time to first entry of PROs.

Methods

All patients followed in DANBIO were informed about DANBIO-from-home by electronic invitations or when attending their clinic. Characteristics of patients who did/did not use DANBIO-from-home in the period after implementation were explored by multivariable logistic regression analyses including demographic and clinical variables (gender, age group, diagnosis, disease duration, use of biological disease-modifying agent (bDMARD), Health Assessment Questionnaire (HAQ), Patient Acceptable Symptom Scale (PASS)). Time from launch to first entry was presented as cumulative incidence curves by age group (<40/40–60/61–80/>80 years).

Results

Of 33 776 patients, 68% entered PROs using DANBIO-from-home at least once. Median (IQR) time to first entry was 27 (11–152) days. Factors associated with data entry in multivariate analyses (OR (95% CI)) were: female gender (1.19 (1.12 to 1.27)), bDMARD treatment (1.41 (1.33 to 1.50)), age 40–60 years (1.79 (1.63 to 1.97)), 61–80 years (1.87 (1.70 to 2.07), or age >80 years (0.57 (0.50 to 0.65)) (reference: age <40 years), lower HAQ (0.68 (0.65 to 0.71)) and PASS ‘no’ (1.09 (1.02 to 1.17). Diagnosis was not associated. Time to first entry of PROs was longest in patients <40 years of age (119 (24–184) days) and shortest in the 61–80 years age group (25 (8–139) days).

Conclusion

A nationwide online platform for PRO in rheumatology achieved widespread use. Higher age, male gender, conventional treatment and disability were associated with no use.

Long-term Behavioral Changes During the COVID-19 Pandemic and Impact of Vaccination in Patients With Inflammatory Rheumatic Diseases

OBJECTIVE

To explore anxiety and self-isolation in patients with inflammatory rheumatic disease (IRD)15 months into the coronavirus disease 2019 (COVID-19) pandemic, including attitudes toward and effects of SARS-CoV-2 vaccination.

METHODS

A nationwide online survey was conducted at 3 timepoints: May 2020, November 2020, and May 2021. Patients with IRD followed in the Danish Rheumatology Quality Registry (DANBIO) were asked about the effects of the pandemic, including SARS-CoV-2 infection and their behavior, anxiety, and concerns. The May 2021 survey included attitudes toward SARS-CoV-2 and influenza vaccination. Characteristics associated with self-isolation in May 2021 were explored with adjusted logistic regression analyses that included patient characteristics and SARS-CoV-2 vaccination status.

RESULTS

Respondents to surveys 1, 2, and 3 included 12,789; 14,755; and 13,921 patients, respectively; 64% had rheumatoid arthritis and 63% were female. Anxiety and concerns were highest in May 2020 and decreased to stable levels in November 2020 and May 2021; 86%, 50%, and 52% of respondents reported self-isolation, respectively. In May 2021, 4% of respondents self-reported previous SARS-CoV-2 infection. The SARS-CoV-2 vaccine acceptance rate was 86%, and the proportion of patients vaccinated against influenza had increased from 50% in winter 2019-2020 to 64% in winter 2020-2021. The proportion of patients with anxiety appeared similar among those vaccinated and unvaccinated against SARS-CoV-2. In multivariable analyses, being unvaccinated, female gender, receiving biologic drugs, and poor quality of life were independently associated with self-isolation.

CONCLUSION

Levels of anxiety and self-isolation decreased after the initial lockdown period in patients with IRD. Half of the patients reported self-isolation in May 2021, a phase that included widespread reopening of society and large-scale vaccination. The lack of prepandemic data prevented a full understanding of the long-term effects of the pandemic on anxiety and self-isolation in patients with IRD.

Reliability and Diagnostic Accuracy of Radiography for the Diagnosis of Calcium Pyrophosphate Deposition: Performance of the Novel Definitions Developed by an International Multidisciplinary Working Group

OBJECTIVE

To assess the reliability and diagnostic accuracy of new radiographic imaging definitions developed by an international multidisciplinary working group for identification of calcium pyrophosphate deposition (CPPD).

METHODS

Patients with knee osteoarthritis scheduled for knee replacement were enrolled. Two radiologists and 2 rheumatologists twice assessed radiographic images for presence or absence of CPPD in menisci, hyaline cartilage, tendons, joint capsule, or synovial membrane, using the new definitions. In case of disagreement, a consensus decision was made and considered for the assessment of diagnostic performance. Histologic examination of postsurgical specimens under compensated polarized light microscopy was the reference standard. Prevalence-adjusted bias-adjusted kappa values were used to assess reliability, and diagnostic performance statistics were calculated.

RESULTS

Sixty-seven patients were enrolled for the reliability study. The interobserver reliability was substantial in most of the assessed structures when considering all 4 readers (κ range 0.59-0.90), substantial to almost perfect among radiologists (κ range 0.70-0.91), and moderate to almost perfect among rheumatologists (κ range 0.46-0.88). The intraobserver reliability was substantial to almost perfect for all the observers (κ range 0.70-1). Fifty-one patients were included in the accuracy study. Radiography demonstrated an overall specificity of 92% for CPPD, but sensitivity remained low for all sites and for the overall diagnosis (54%).

CONCLUSION

The new radiographic definitions of CPPD are highly specific against the gold standard of histologic diagnosis. When the described radiographic findings are present, these definitions allow for a definitive diagnosis of CPPD, rather than other calcium-containing crystal depositions; however, a negative radiographic finding does not exclude the diagnosis.

Optical Coherence Tomography of Peripapillary Vessels in Giant Cell Arteritis and Ischaemic Ocular Disease

With normal retinal blood flow, cross-sectional optical coherence tomography (OCT) of retinal vessels shows a structured intravascular reflectivity profile, resembling a 'figure-of-8'. Altered profiles have been reported in vascular occlusive and haematological diseases. Giant cell arteritis (GCA) can cause visual loss, usually due to anterior ischaemic optic neuropathy (AION) or retinal artery occlusion. Our aim was to extend the assessment of OCT vascular profiles to patients with suspected GCA and to determine if any abnormalities were related to GCA per se or to ischaemic ocular conditions. This nested retrospective study included 61 eyes of 31 patients (13 with GCA). Six eyes had arteritic and seven eyes non-arteritic AION, three eyes had non-arteritic retinal artery occlusion, 11 eyes had other ocular conditions and 34 were unaffected control eyes. For each eye the appearance of structured intravascular profiles on peripapillary OCT was graded as present, partial, absent or uncertain. Non-presence of structured intravascular profiles was more frequent in AION and retinal artery occlusion than in other ocular conditions or unaffected eyes (Fisher's test, p = .0047). Based on follow-up of 25 eyes, reflectivity profiles normalised in three out of four eyes after 85 (35-245) days. Vessel profiles were not associated with GCA (p = .32) and were similar in arteritic and non-arteritic AION (p = .66). In conclusion, absence of structured intravascular reflectivity profiles may be a marker of acute ischaemia in the anterior optic nerve or inner retina. However, it did not seem specific for GCA. The prognostic value warrants further studies.

Ultrasound joint examination by an automated system versus by a rheumatologist: from a patient perspective

Background

The Arthritis Ultrasound Robot (ARTHUR) is an automated system for ultrasound scanning of the joints of both hands and wrists, with subsequent disease activity scoring using artificial intelligence. The objective was to describe the patient’s perspective of being examined by ARTHUR, compared to an ultrasound examination by a rheumatologist. Further, to register any safety issues with the use of ARTHUR.

Methods

Twenty-five patients with rheumatoid arthritis (RA) had both hands and wrists examined by ultrasound, first by a rheumatologist and subsequently by ARTHUR. Patient-reported outcomes (PROs) were obtained after the examination by the rheumatologist and by ARTHUR. PROs regarding pain, discomfort and overall experience were collected, including willingness to be examined again by ARTHUR as part of future clinical follow-up. All ARTHUR examinations were observed for safety issues.

Results

There was no difference in pain or discomfort between the examination by a rheumatologist and by ARTHUR (p = 0.29 and p = 0.20, respectively). The overall experience of ARTHUR was described as very good or good by 92% (n = 23), with no difference compared to the examination by the rheumatologist (p = 0.50). All (n = 25) patients were willing to be examined by ARTHUR again, and 92% (n = 23) would accept ARTHUR as a regular part of their RA clinical follow up. No safety issues were registered.

Conclusions

Joint ultrasound examination by ARTHUR was safe and well-received, with no difference in PRO components compared to ultrasound examination by a rheumatologist. Fully automated systems for RA disease activity assessment could be important in future strategies for managing RA patients.

Trial registration: The study was evaluated by the regional ethics committee (ID: S-20200145), which ruled it was not a clinical trial necessary for their approval. It was a quality assessment project, as there was no intervention to the patient. The study was hereafter submitted and registered to Odense University Hospital, Region of Southern Denmark as a quality assessment project and approved (ID: 20/55294).

Urate crystal deposition is associated with inflammatory markers and carotid artery pathology in patients with intercritical gout: results from the NOR-Gout study

BACKGROUND

Gout is of unknown reason associated with cardiovascular disease. Ultrasound is sensitive for detecting crystal deposition and plasma calprotectin is a sensitive inflammatory marker. This study explores the associations between crystal deposition, inflammation and carotid artery pathology.

METHOD

A cross-sectional analysis of baseline assessments from the NOR-Gout study was undertaken. Crystal deposition was assessed by ultrasound (double contour, tophi, aggregates) and dual-energy CT (DECT) and laboratory assessments included plasma calprotectin. The carotid arteries were bilaterally examined for carotid intima-media thickness (cIMT) and presence of plaques. Spearman correlations, Mann-Whitney tests and linear regression analyses were used to explore associations between crystal deposition, inflammatory markers,and carotid pathology.

RESULTS

202 patients with intercritical gout (95.5% men, mean (SD) age 56.5 (13.8) years, disease duration 7.9 (7.7) years) were included. Calprotectin was correlated with all scores of crystal deposition by ultrasound (r=0.26-0.32, p<0.001) and DECT (r=0.15, p<0.05). cIMT was correlated with sum score aggregates (r=0.18-0.22, p<0.05). Patients with large tophi had higher levels of calprotectin as well as more frequent carotid plaque (p<0.05).

CONCLUSIONS

Study findings point towards crystal deposition contributing to subclinical inflammation with subsequent vascular implications. However, future longitudinal studies are needed to confirm such causal relationships.

Influence of Genetics, Immunity and the Microbiome on the Prognosis of Inflammatory Bowel Disease (IBD Prognosis Study): the protocol for a Copenhagen IBD Inception Cohort Study

INTRODUCTION

Inflammatory bowel diseases (IBD), encompassing Crohn's disease and ulcerative colitis, are chronic, inflammatory diseases of the gastrointestinal tract. We have initiated a Danish population-based inception cohort study aiming to investigate the underlying mechanisms for the heterogeneous course of IBD, including need for, and response to, treatment.

METHODS AND ANALYSIS

IBD Prognosis Study is a prospective, population-based inception cohort study of unselected, newly diagnosed adult, adolescent and paediatric patients with IBD within the uptake area of Hvidovre University Hospital and Herlev University Hospital, Denmark, which covers approximately 1 050 000 inhabitants (~20% of the Danish population). The diagnosis of IBD will be according to the Porto diagnostic criteria in paediatric and adolescent patients or the Copenhagen diagnostic criteria in adult patients. All patients will be followed prospectively with regular clinical examinations including ileocolonoscopies, MRI of the small intestine, validated patient-reported measures and objective examinations with intestinal ultrasound. In addition, intestinal biopsies from ileocolonoscopies, stool, rectal swabs, saliva samples, swabs of the oral cavity and blood samples will be collected systematically for the analysis of biomarkers, microbiome and genetic profiles. Environmental factors and quality of life will be assessed using questionnaires and, when available, automatic registration of purchase data. The occurrence and course of extraintestinal manifestations will be evaluated by rheumatologists, dermatologists and dentists, and assessed by MR cholangiopancreatography, MR of the spine and sacroiliac joints, ultrasonography of peripheral joints and entheses, clinical oral examination, as well as panoramic radiograph of the jaws. Fibroscans and dual-energy X-ray absorptiometry scans will be performed to monitor occurrence and course of chronic liver diseases, osteopenia and osteoporosis.

ETHICS AND DISSEMINATION

This study has been approved by Ethics Committee of the Capital Region of Denmark (approval number: H-20065831). Study results will be disseminated through publication in international scientific journals and presentation at (inter)national conferences.

POS0373 WHO ARE IN AND WHO ARE NOT? CHARACTERISTICS OF PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES ACCEPTING AN ONLINE SYSTEM FOR REMOTELY ENTERING PATIENT REPORTED OUTCOMES. EXPERIENCE FROM THE DANISH DANBIO REGISTRY

Background

Digital solutions for online monitoring of chronic diseases are increasingly implemented in health care, but not all patients might have access, skills, or interest in using them. Fueled by the COVID-19 pandemic and the urgent need for remote consultations, an online website to enter patient-reported outcomes (PROs) from home (DANBIO-from-home, https://danbio.dk) was implemented on May 15th 2020 for patients with inflammatory rheumatic diseases (IRD) followed in the Danish nationwide DANBIO registry.

Objectives

To explore the use of DANBIO-from-home during the first 1½ year after launching, with focus on a) characteristics of patients who did versus who did not access the webpage, and b) impact of patient age on time to first entry.

Methods

DANBIO-from-home allows PROs to be entered remotely by computer, tablet, or smartphone after secure log-on. All patients followed in DANBIO were informed about this option by invitations sent through eBoks, a national infrastructure for electronic communication, available to 80-90% of Danish citizens. Patients were encouraged to access DANBIO-from-home before planned rheumatology consultations, or when participating in the voluntary questionnaire survey ‘You and your rheumatic disease during times with corona-virus’ (on three occasions: May 2020, Nov 2020, June 2021) (ref). Follow-up ended Dec 1st 2021.

Characteristics of patients who did/did not access DANBIO-from-home during follow-up are explored by multivariable logistic regression analyses adjusted by clinical factors (gender/age-group/diagnosis/disease duration/use of biologics/HAQ/PASS). Time to first entry of PRO using DANBIO-from-home is presented as cumulative incidence curves by age group.

Results

Among 33,776 patients with inflammatory rheumatic diseases followed in DANBIO, 68% used DANBIO-from-home at least once during follow-up (Table 1). Patients who used the system were less frequently below 40 years or above 80 years old, more frequently biologically treated and had lower HAQ-score than patients who did not use it.

Table 1.Data entry, DANBIO-from-home solution N=33,776YES, 68%NO, 32%Gender, female6436Gender, male7822Age strata, yrs< 40623840-60732761-807228>803961DiagnosisRA6723AxSpA6931PsA7030Biologic treatment, yes*7327PASS, yes7129Age, yrs, median (IQR)62 (52-71)65 (50-77)Time since diagnosis, yrs, median (IQR)9 (5-16)10 (5-17)HAQ, median (IQR)0.5 (0.125-1.0)0.625 (0.125-1.25)

Row percentages unless otherwise shown

* latest visit before March 2020

AxSpA: Axial spondyloarthritis, HAQ: health assessment questionnaire, PASS: patient acceptable symptom scale, PsA: psoriatic arthritis, RA: rheumatoid arthritis

In logistic regression analyses, factors associated with DANBIO-from-home access were: female gender (odds ratio, OR 1.2 (1.1;1.3)), age group 40-60 (1.8 (1.6;2.0)) or 61-80 yrs (1.9 (1.7;2.19) and not age >80 yrs (0.6 (0.5;0.7) with age <40 as the reference), biologic treatment (1.4 (1.3;1.5)), higher HAQ (1.3 (0.3;1.4)), scoring PASS ‘no’ (1.1 (1.02;1.2)) (all p <0.001), whereas disease duration and diagnosis had no impact.

Time to first entry was longest in in patients >80 yrs followed by the <40 yrs group. For all age-groups, and most pronounced for age <40 yrs, the use increased when invitations to questionnaire surveys were sent out. (Figure 1)

Conclusion

A web-based system for secure remote entry of PROs was well-received after a nationwide launch. Patient-related factors had a substantial impact on the use. Lower use in the elderly might indicate lack of technical skills or facilities, whereas low use in younger age groups, which improved over time, is likely driven by other factors. Further analyses are planned to explore if lack of use impacts treatment outcomes.

References

[1]Glintborg et al, Rheumatology. 2021 Oct 9;60:SI3-SI12

Disclosure of Interests

Bente Glintborg Grant/research support from: AbbVie, BMS, Pfizer, Dorte Vendelbo Jensen: None declared, Lene Terslev Speakers bureau: Roche, Novartis, Pfizer, UCB, Janssen, Oliver Hendricks Grant/research support from: AbbVie, Novartis, Pfizer, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Galapagos, Gilead, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Celgene, Merck, Novartis, Simon Horskjær Rasmussen: None declared, Mogens Pfeiffer-Jensen: None declared, Thomas Adelsten: None declared, Ada Colic: None declared, Kamilla Danebod: None declared, Malene Kildemand: None declared, Anne Gitte Loft Speakers bureau: AbbVie, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, and UCB, Heidi Lausten Munk: None declared, Jens Kristian Pedersen: None declared, René Østgård Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Eli-Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi and UCB., Grant/research support from: Abbvie, Christian Møller Sørensen: None declared, Niels Steen Krogh: None declared, Jette Nørgaard Agerbo: None declared, Connie Ziegler: None declared, Merete Lund Hetland Grant/research support from: AbbVie, Biogen, BMS, Celtrion, Eli Lilly Denmark A/S, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopis, Sandoz

OP0287 LONGITUDINAL ASSESSMENT OF THE ULTRASOUND GOUT LESIONS USING THE VALIDATED OMERACT SEMI-QUANTITATIVE SCORING SYSTEM

Background

In gout, ultrasound (US) is a promising tool to detect changes in monosodium urate (MSU) depositions during urate-lowering therapy (ULT). The OMERACT US group has developed definitions of gout-specific US lesions[1] and a semi-quantitative scoring system for US lesions representing MSU deposition (tophus, double contour (DC) and aggregates)[2], but the responsiveness of lesions when applying this scoring system has not yet been assessed.

Objectives

The primary aim was to evaluate the responsiveness of gout-specific US lesions in patients receiving treat-to-target ULT using both a binary (present/absent) and the OMERACT-defined semi-quantitative (0-3) scoring system. The secondary aims were to determine the most responsive US measure for MSU deposition at patient level and the optimal joint/tendon set for monitoring lesions.

Methods

US (28 joints, 14 tendons) was performed in microscopically verified gout patients initiating/increasing ULT and repeated after 6 and 12 months. Static images and videos of pathologies were stored. Tophus, DC and aggregates were scored binarily and semi-quantitatively. Individual lesion-scores were calculated at patient level as were combined crystal sum scores. Standardised response means (SRM) for lesions when scored binarily and semi-quantitatively were calculated at patient and joint/tendon level.

Results

Sixty-three patients were followed for 12 months. Plasma urate levels were effectively lowered during follow-up (Table 1). US showed statistically significant decreases in tophus and DC sum scores, both when scored binarily and semi-quantitatively, whereas aggregates were almost unchanged during follow-up (Table 1). SRMs for the semi-quantitative tophus and DC sum scores were markedly higher than those for the binary. The most responsive measure for urate deposition at patient level was a combined semi-quantitative tophus-DC-sum score (SRM 0.92, Table 1). A reduced joint/tendon set for monitoring included knee and 1st–2nd metatarsophalangeal joints and peroneus and distal patella tendons representing the most prevalent and responsive sites (SRM 1.13, Figure 1).

Table 1.

Course and SRMs of US scores during 12 months’ follow-up

Baseline6-months’ follow-up12-months’ follow-upP-value*SRMMeanMedian [IQR]MeanMedian [IQR]MeanMedian [IQR]Δ 0–6 monthsΔ 6–12 monthsΔ 0–12 months12 monthsP-urate (mmol/L)0.490.48 [0.42;0.56]0.330.32 [0.29; 0.36]0.310.30 [0.27;0.35]<0.0010.0464<0.001-SQ ultrasound scoring (0–3), [possible range]:DC sum score, [0–84]5.53 [1; 8]3.72 [0; 5]2.21 [0; 4]<0.001<0.001<0.0010.80Tophus sum score, [0–126]9.56 [4; 11]8.25 [3; 9]6.44 [2; 7]<0.001<0.001<0.0010.84Aggregates sum score, [0–126]12.210 [7; 16]12.610 [7; 16]11.811 [6; 15]0.8750.1920.5820.07SQ-TD-sum score, [0–210]15.010 [6; 16]11.98 [5; 12]8.76 [4; 9]<0.001<0.001<0.0010.92SQ-TDA-sum score, [0–336]27.222 [14; 30]24.618 [12; 28]20.516 [9; 25]<0.001<0.001<0.0010.73Binary ultrasound scoring (0–1), [possible range]:DC sum score, [0–28]1.81 [0; 3]1.11 [0; 2]0.60 [0; 1]<0.001<0.001<0.0010.72Tophus sum score, [0–42]3.42 [1; 4]3.02 [1; 3]2.32 [0; 3]0.002<0.001<0.0010.75Aggregates sum score, [0–42]4.43 [2; 6]4.74 [2; 6]4.24 [2; 6]0.3560.1250.7320.07Binary-TD-sum score, [0–70]5.33 [2; 6]4.23 [1; 4]2.92 [1; 3]<0.001<0.001<0.0010.86Binary-TDA-sum score, [0–112]9.78 [5; 11]8.87 [4; 10]7.16 [3; 9]<0.0010.001<0.0010.70

US, ultrasound; SQ, semi-quantitative; SRM, standardised response mean; DC, double contour; TD-sum score, tophus+DC sum score, TDA-sum score, tophus+DC+aggregates sum score. * Wilcoxon signed rank test, statistically significant results are indicated by bold-face type.

Conclusion

The OMERACT consensus-based semi-quantitative US gout scoring system showed longitudinal validity with both tophus and DC being highly responsive to treatment. A responsive US measure for urate deposition and a feasible joint/tendon set for monitoring are proposed.

References

[1]Gutierrez et al. 2015.

[2]Christiansen et al. 2021.

Acknowledgements

The Danish Rheumatism Association is acknowledged for financial support of the salary of SNC.

Disclosure of Interests

Sara Nysom Christiansen Speakers bureau: SNC has received speaker fees from BMS and GE, Grant/research support from: SNC has received funding from Novartis, Mikkel Østergaard Speakers bureau: MØ has received research support and/or consultancy/speaker fees from Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Centocor, GSK, Gilead, Galapagos, Hospira, Janssen, Merck, Mundipharma, Novartis, Novo, Orion, Pfizer, Regeneron, Schering-Plough, Roche, Takeda, UCB and Wyeth., Grant/research support from: MØ has received research support and/or consultancy/speaker fees from Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Centocor, GSK, Gilead, Galapagos, Hospira, Janssen, Merck, Mundipharma, Novartis, Novo, Orion, Pfizer, Regeneron, Schering-Plough, Roche, Takeda, UCB and Wyeth., Ole Slot: None declared, Viktoria Fana: None declared, Lene Terslev Speakers bureau: LT has received speakers’ fees from AbbVie, MSD, Novartis, Roche, Pfizer, GE, BMS and Janssen.

EULAR points to consider for the use of imaging to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs)

OBJECTIVES

To develop evidence-based Points to Consider (PtC) for the use of imaging modalities to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs).

METHODS

European Alliance of Associations for Rheumatology (EULAR) standardised operating procedures were followed. A systematic literature review was conducted to retrieve data on the role of imaging modalities including ultrasound (US), fluoroscopy, MRI, CT and fusion imaging to guide interventional procedures. Based on evidence and expert opinion, the task force (25 participants consisting of physicians, healthcare professionals and patients from 11 countries) developed PtC, with consensus obtained through voting. The final level of agreement was provided anonymously.

RESULTS

A total of three overarching principles and six specific PtC were formulated. The task force recommends preference of imaging over palpation to guide targeted interventional procedures at peripheral joints, periarticular musculoskeletal structures, nerves and the spine. While US is the favoured imaging technique for peripheral joints and nerves, the choice of the imaging method for the spine and sacroiliac joints has to be individualised according to the target, procedure, expertise, availability and radiation exposure. All imaging guided interventions should be performed by a trained specialist using appropriate operational procedures, settings and assistance by technical personnel.

CONCLUSION

These are the first EULAR PtC to provide guidance on the role of imaging to guide interventional procedures in patients with RMDs.

AB1563-HPR TRAINING AND ASSESSMENT OF MUSCULOSKELETAL ULTRASOUND AND INJECTION SKILLS - A SYSTEMATIC REVIEW

Background

The importance of international harmonization regarding education of rheumatologists in musculoskeletal ultrasound (MSUS) and injection skills have been highlighted in several studies, including the need for standardized training programs containing competency-based education using validated assessment tools [1-2].

Objectives

To examine how residents are trained and assessed in MSUS, MSUS-guided and landmark-guided joint aspiration and injection. Additionally, to present the available assessment tools and examine their supporting validity evidence.

Methods

A systematic search of PubMed, Cochrane Library, and Embase was conducted in accordance with the PRISMA guidelines and studies published from January 1, 2000 to May 31, 2021 were included. Two independent reviewers performed the search and data extraction. The studies were evaluated using the Medical Education Research Quality Instrument (MERSQI).

Results

9,884 articles were screened and 43 were included; 3 randomized studies, 21 pre- and post-test studies, 16 descriptive studies (Table 1), and 3 studies developing assessment tools. The studies used various theoretical training modalities e.g. lectures, anatomical quizzes, and e-learning. The practical training models varied from mannequins and cadavers to healthy volunteers and patients. Most studies used subjective “comfort level” as assessment, others used practical examination and/or theoretical examination. All training programs increased trainees’ self-confidence, theoretical knowledge, and/or practical performance, however few used validated assessment tools to measure the effect. Only one study met the MERSQI high methodical quality cut-off score of 14.

Table 1.

Description of included studies examining training of MSUS, MSUS-guided or landmark-guided joint aspiration and injection skills.

Study characteristicsMSUSMSUS-guidedLandmark-guidedNo. of studiesa14323Study design003 Randomized2217 Pre- and post-test1213 DescriptiveParticipantsb408381388 Residents1-8 Experts149 Medical students47 OthersAssessmentc71-  Objective--2  Practical2113  Theoretical518 Subjective  Questionnaire    MixedMERSQId9.27.58.9 Mean score

Legend:aStudies developing assessment tools are not included in this table.bAccumulated number of participants enrolled in the studies.cNumber of studies.dMean score using the Medical Education Research Study Quality Instrument, maximum score =18.

Conclusion

The included studies were heterogeneous, and most were of poor methodological quality and not based on contemporary educational theories. This review highlights the need for educational studies using validated theoretical and practical assessment tools to ensure optimal MSUS training and assessment in rheumatology.

References

[1]Naredo E, D’Agostino MA, Conaghan PG, Backhaus M, Balint P, Bruyn GAW, et al. Current state of musculoskeletal ultrasound training and implementation in Europe: Results of a survey of experts and scientific societies. Rheumatology 2010;49:2438–43.

[2]Mandl P, Naredo E, Conaghan PG, D’Agostino M-A, Wakefield RJ, Bachta A, et al. Practice of ultrasound-guided arthrocentesis and joint injection, including training and implementation, in Europe: results of a survey of experts and scientific societies. Rheumatology 2012;51:184–90.

Acknowledgements

We thank Tove Margit Svendsen, research librarian at the Medical library at Rigshospitalet Denmark, for her assistance with developing the search string for the systematic review.

Disclosure of Interests

None declared

POS1197 REMOTE AND PHYSICAL CONSULTATIONS DURING THE FIRST 15 MONTHS OF THE COVID-19 PANDEMIC: USE AND PATIENT-SATISFACTION IN PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES FOLLOWED IN THE DANBIO REGISTRY

Background

During COVID-19 related lockdowns, physical attendance may be replaced by remote (by telephone, email, video consultations in patients with inflammatory rheumatic diseases (IRD). During re-opening of society, reallocation of health-care resources could potentially cause persistent changes in access to physical consultations.

Objectives

To explore use of remote consultations in patients with IRD followed in the nationwide DANBIO registry at three time points (lockdown from spring 2020 followed by gradual reopening of society) during the COVID-19 pandemic. Furthermore, to explore satisfaction with treatment access, and preferred mode of consultation including potentially associated clinical factors.

Methods

We performed a nationwide survey where three times, an online questionnaire (Q) “You and your arthritis in times of COVID-19” with questions regarding use of and access to remote and physical consultations was sent to all patients in DANBIO (Q1: March-April 2020, Q2: November 2020, Q3: May 2021). (ref)

Patient characteristics were captured in DANBIO (gender/age/diagnosis/biological therapy) and from the questionnaire (work status/comorbidities/EQ-5D). Use of physical and/or remote consultations 0-3 months before surveys and satisfaction with access was identified. Clinical factors associated with a preference for physical consultations at time of Q3 (versus remote contact (telephone/e-mail/video)) were explored with multivariable logistic regression analysis.

Results

Totally, 12,789/14,755/13,921 patients responded to Q1/Q2/Q3, respectively, with 23,311 unique patients participating in at least one survey. Characteristics of patients responding to Q3 are shown in Table 1.

Table 1.

Respondents to questionnaire 3, n=13,921.

GenderFemale63%Median age, IQR, years64 (54-72)DiagnosisRheumatoid arthritis64%Psoriatic arthritis16%Axial spondyloarthritis (AxSpA)12%Other8%Current occupational statusWorking41%No. of self-reported comorbidities≥165%Current biologic useyes27%*EQ-5D, median (IQR)0.8 (0.7-0.9)

EQ-5D: EuroQol quality of life (5-dimension)

*By March 2020

During the preceding 3 months, proportions of patients with physical/remote consultations were 22%/45%, 41%/38%, 40%/39% for Q1, Q2, Q3, respectively. Remote consultations were mainly by telephone, whereas email (<5%) and video (<1%) were rarely used. In all three surveys, only 7% of respondents found that access to counseling with their rheumatologist had deteriorated during the pandemic (Figure 1A) whereas the majority found it to be unchanged or did not know. The preferred contact form was physical consultations (68-74%, Figure 1B, not available for Q1). Factors associated with preference for physical consultation were female gender, higher age (>60 years), biological treatment, low EQ-5D and not having axial spondyloarthritis, whereas work status and comorbidities were without significance (logistic regression analyses, details not shown).

Figure 1.

Conclusion

Despite a widespread use of remote consultations during the pandemic, nationwide questionnaire surveys performed at three time-points during the COVID-19 pandemic showed that most patients were satisfied with access to rheumatic counseling. Nevertheless, in-person contacts were preferred by most patients, mainly women and elderly.

References

[1]Glintborg B, al. RMD Open. 2021;7(1).

Acknowledgements

Patients and Danish departments contributing to the DANBIO registry. Lundbeck foundation for funding

Disclosure of Interests

Bente Glintborg Grant/research support from: AbbVie, BMS, Pfizer, Dorte Vendelbo Jensen: None declared, Lene Terslev Speakers bureau: Roche, Novartis, Pfizer, and UCB, Oliver Hendricks Grant/research support from: AbbVie, Novartis, Pfizer, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Galapagos, Gilead, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Celgene, Merck, Novartis, Simon Horskjær Rasmussen: None declared, Mogens Pfeiffer-Jensen: None declared, Thomas Adelsten: None declared, Ada Colic: None declared, Kamilla Danebod: None declared, Malene Kildemand: None declared, Anne Gitte Loft Speakers bureau: AbbVie, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, and UCB, Heidi Lausten Munk: None declared, Jens Kristian Pedersen: None declared, René Østgård: None declared, Christian Møller Sørensen: None declared, Niels Steen Krogh: None declared, Jette Nørgaard Agerbo: None declared, Connie Ziegler: None declared, Merete Lund Hetland Grant/research support from: AbbVie, Biogen, BMS, Celtrion, Eli Lilly Denmark A/S, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopis, Sandoz

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

AB1354 ULTRASOUND JOINT EXAMINATION BY AN AUTOMATED SYSTEM VERSUS BY A RHEUMATOLOGIST – FROM A PATIENT PERSPECTIVE

Background

The Arthritis Ultrasound Robot (ARTHUR) is an automated system for ultrasound scanning of the joints of both hands and wrists, with subsequent disease activity scoring using artificial intelligence.

Objectives

To describe the patients’ perspective of being examined by ARTHUR, compared to an ultrasound examination by a rheumatologist. Further, to register any safety issues in the use of ARTHUR.

Methods

Twenty-five patients with rheumatoid arthritis (RA) had both hands and wrists examined by ultrasound, first by a rheumatologist subsequently by ARTHUR (see Figure 1 A, B and C). Patient-reported outcomes (PRO) were obtained after the examination by the rheumatologist and then again after the examination by ARTHUR. PROs regarding pain, discomfort and overall experience were collected. In addition, willingness to be scanned again by ARTHUR as part of future clinical follow-up was also collected. All ARTHUR examinations were observed for safety issues.

Figure 1.

A. The rheumatologist is performing the ultrasound examination. B. The ARTHUR system used in this trial used a GE Logiq 10 ultrasound scanner. C. ARTHUR started ultrasound scanning a RA patient. The patient follows the instructions given on the touchscreen and by audio. D. Overall experience with ultrasound scanning by Rheumatologist and ARTHUR.

Results

For baseline characteristics of RA patients, see Table 1.

Table 1.

Baseline Characteristics. CRP: C-reactive protein; DAS28CRP: Disease Activity Score in 28 joints combined with CRP value, RF: Rheumatoid factor antibody, CCP: cyclic citrullinated peptide antibodies.

Table 1PatientsPatients, n25Age (SD)63,7 (12,22)Female, n (%)17 (68 %)Erosive disease, n (%)10 (40%)RF and/or CCP-positive, n (%)17 (68%)DAS28CRP (SD)2.8 (1.2)

There was no difference in pain or discomfort between the examination by a rheumatologist and by ARTHUR (p=0.29 and p=0.20, respectively). The overall experience of an examination by ARTHUR (see Figure 1 D) was described as very good or good by 92% (n=23), with no difference compared to the examination by the rheumatologist (p=0.50). All (n=25) patients were willing to be examined by ARTHUR again, and 92% (n=23) would accept ARTHUR as a regular part of their RA clinical follow up. No safety issues were registered.

Conclusion

Joint ultrasound examination by ARTHUR was safe and well-received, with no difference in PRO components compared to ultrasound examination by a rheumatologist. Fully automated systems for joint disease activity assessment could be important in future strategies for RA management.

Disclosure of Interests

Bill Aplin Frederiksen: None declared, Maja Schousboe: None declared, Lene Terslev: None declared, Nikolaj Iversen: None declared, Hanne Merete Lindegaard: None declared, Thiusius Rajeeth Savarimuthu Shareholder of: Cofounder of the robotics company ROPCA, developing ARTHUR., Søren Andreas Just Shareholder of: Cofounder of the robotics company ROPCA, developing ARTHUR.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Disclosure of Interests

None declared

POS0276 TRADITION VS INNOVATION! CONVENTIONAL RADIOGRAPHY AND ULTRASOUND IN THE DIAGNOSIS OF CPPD: INSTRUCTIONS FOR USE

Background

Conventional radiography (CR) is widely used as the first-line investigation for calcium pyrophosphate deposition (CPPD) disease, given its widespread use and the low cost. Next to it a series of advanced imaging techniques have been evaluated for accuracy and reliability. Among them, ultrasound (US) has been thoroughly tested and demonstrated to be accurate and reliable for CPPD diagnosis. However, even if there are data on the diagnostic accuracy of US and CR alone, it is not clear if performing both diagnostic tests and in which sequential order provides an added value for the diagnosis of CPPD.

Objectives

The aim of this study was to assess which diagnostic test performs better for the diagnosis of CPPD and if a combination of the two exams provides an additional value.

Methods

This is an ancillary study of the criterion validity of US in CPPD study1. Consecutive patients with knee osteoarthritis requiring total joint replacement were enrolled in 8 centres. Participants underwent US and CR of the affected knee prior to surgery. US was performed by experienced sonographers following the same scanning protocol described in the main study, while CR were performed in weight bearing AP and lateral views and were read by 2 experienced radiologists that reached a consensus on the presence/absence of CPPD. The evaluation of CPPD at the level of menisci and hyaline cartilage (HC) was based on the OMERACT definitions for US and on the new definitions developed by the ACR/EULAR CPPD classification criteria working group for CR [paper under submission]. Patients were classified as having CPPD considering histological examination as reference standard. Diagnostic indexes were calculated for US and CR alone and combined. Poisson models with robust estimation were used to estimate the best sequence of these diagnostic methods for a more accurate diagnosis of CPPD.

Results

51 pts were enrolled (63% F, mean age 74y ± 8). Diagnostic indexes of US and CR alone and combined are indicated in Table 1. Compared to histology, US demonstrated to be a sensitive tool for identification of CPPD at the knee, with a good sensitivity in all sites and in the overall evaluation. Instead, CR was less sensitive, but it was a highly specific exam for CPPD identification. Combining US and CR led to a higher sensitivity compared with CR alone, but a lower specificity compared to both CR and US alone, and it offered no additional increase in diagnostic accuracy. The Figure 1 shows the results of the appropriate sequence of use of US and CR in patients with suspected CPPD: in case of a positive CR at any of the 3 sites (menisci and HC) no additional exam is necessary, and the same in case of a positive US in at least two sites; however in case of a negative CR, US could help in a statistically significant way to identify CPPD patients, and further in case of a positive US in a single site CR can offer additional information.

Table 1.

diagnostic indexes of US, CR and US + CR in the identification of CPPD. MM: medial meniscus, LM: lateral meniscus, HC: hyaline cartilage, SN: sensitivity, SP: specificity, PPV: positive predictive value, NPV: negative predictive value, ACC: accuracy.

USSNSPPPVNPVACCMM0.880.810.820.880.84LM0.880.730.760.860.80HC0.780.860.820.830.82Overall0.920.640.730.890.78CRMM0.32110.610.67LM0.400.960.910.630.69HC0.480.930.850.680.73Overall0.540.920.880.660.73US + CRMM0.880.810.820.880.84LM0.920.690.740.900.80HC0.870.820.800.890.84Overall0.920.560.670.880.75Figure 1.

evaluation of sequence of US and CR

Conclusion

US confirmed a high diagnostic accuracy in identifying patients affected by CPPD at knee level, while CR demonstrated a high specificity but a low sensitivity. Performing both diagnostic tests could make sense in case of a negative CR or in case of an inconclusive US (only one positive site). To our knowledge, this is the first study that investigates the role of the combination of the two exams in CPPD. Further studies in a large number of patients and in different joints would be helpful to address this point.

References

[1]Filippou G. et al, Ann Rheum Dis, 2020

Disclosure of Interests

None declared

POS0131 CONCORDANCE BETWEEN LOCATION OF SELF-REPORTED SITE OF MUSCULOSKELETAL PAIN IN PSORIASIS AND FINDINGS OF INFLAMMATION BY ULTRASOUND

Background

Patients with psoriasis (PsO) often report muskuloskeletal (MSK) pain without clinical findings of inflammation. Ultrasound (US) is more sensitive than clinical evaluation in detecting synovitis and enthesitis, and we have previously found that patients with PsO and pain more often have US signs of inflammation in joints and entheses than patients without pain (1), indicating possible psoriatic arthritis (PsA). Whether the area of reported pain in these patients correspond to inflammation by US has not yet been investigated.

Objectives

In patients with PsO with self-reported MSK pain, to investigate if the area of reported of pain corresponds to synovitis and/or enthesitis.

Methods

PsO patients with self-reported MSK pain (n=79, Table 1), recruited from a Danish nationwide survey, were evaluated in one of four rheumatology departments with greyscale (GS) and color Doppler (CD) US of 48 joints and 12 entheses, applying the OMERACT scoring systems (2) for US synovitis (defined as GS score ≥2 or CD≥1) and enthesitis (defined as ≥1 GS inflammatory finding (hypoechogenicity/thickening) and CD score ≥1). Patients indicated the location of current pain in 21 areas on a homunculus, out of which shoulder (joint), elbow (joint and common extensor enthesis), hand (wrist and MCP, PIP, and DIP-joints 1-5), knees (joint and quadriceps- and patellar entheses), feet (ankle and MTP-joints 1-5) and heel (Achilles- and plantar fascia entheses) were evaluated by US, se Figure 1. Association between self-reported pain and US inflammation (synovitis/enthesitis) was explored using Fisher’s exact test and odds ratios (OR) for 2x2 tables. Agreement was calculated using Cohen’s kappa (κ).

Table 1.

Population characteristics (n=79)

Sex (female)33 (42)Age (years)57 (47-66)Body Mass Index (kg/m2)28.4 (24.8-34.8)Disease duration PsO (years)25 (11-39)Swollen joint count (0-66)0 (0-1)Tender joint count (0-68)2 (0-5)Tender enthesis count (0-16)1 (0-2)Fibromyalgia tender point count (0-18)1 (0-5)Psoriasis Area and Severity Index (0-72)1.5 (0.2-4.2)Nail psoriasis (presence)26 (33)Physician VAS (0-100)3 (1-6)CRP (mmol/l)2.1 (0.5-4.1)Global VAS (0-100)16 (4-45)Pain VAS (0-100)20 (5-39)Health Assessment Questionnaire (0-3)0.25 (0.00-0.69)DAS28-CRP (0-10)1.6 (1.5-2.6)Disease Activity in Psoriatic Arthritis (0-164)5.2 (4.1-20.7)

Numbers are median (IQR) or no. (%). CRP: C-reactive protein, DAS28: Disease Activity Score - 28 joints, VAS: Visual Analog Scale

Figure 1.

Self-reported pain versus ultrasound (US) inflammation in different areas, and in all areas considered together, presented as 2x2 tables and corresponding odds ratios (OR, p-value) (Fisher’s exact test), and agreement (Cohens Kappa (κ (95% confidence interval)).

Results

Of the areas examined by US, pain was most frequent in the knees (41% of patients), while US inflammation was most frequent in the hand/wrist (55%). In total, US inflammation was found in of 72% patients (synovitis in 71%, enthesitis in 17%). In 47% of patients, US inflammation was found in one or more of the painful sites. Figure 1 shows 2x2 tables of pain versus US inflammation in different areas and corresponding ORs and κ-values. Self-reported pain was significantly related to US inflammation in that area, both overall (OR=3.1, p>0.001) and for the specific areas of the left hand (OR 3.1, p=0.03) and right elbow (OR 18.3, p=0.01). Agreement between self-reported pain and US inflammation, as measured by κ, was overall low, κ =0.18(95% confidence interval 0.10-0.27), with highest agreement found for the right elbow (κ = 0.30(-0.9-0.68)). Pain only in areas not examined by US (back/hips/breastbone/jaw) was indicated by 16% of patients.

Conclusion

While US signs of synovitis and enthesitis is frequent in patients with PsO and pain, concordance between US inflammation and the specific location of pain is only seen in half of the patients.

References

[1]Felbo SK et al., Rheumatology (Oxford), 2021.

[2]Bruyn GA et al., The Journal of Rheumatology, 2019

Acknowledgements

The authors would like to thank all participating patients, physicians, laboratory staff, study nurses and secretaries who contributed to this study, Amgen/Celgene for financial study support and The Danish Rheumatism Association and The Danish Psoriasis Research Foundation for support of the work of SKF.

Disclosure of Interests

Sara Kamp Felbo Grant/research support from: Amgen/Celgene, Lene Terslev Speakers bureau: AbbVie, Janssen, Roche, Novartis, Pfizer, MSD, BMS and GE, Inge Juul Sørensen: None declared, Oliver Hendricks Speakers bureau: Abbvie, Pfizer and Novartis, Dorota Kuettel: None declared, Rasmus Lederballe Pedersen: None declared, stavros chrysidis: None declared, Mikkel Østergaard Speakers bureau: AbbVie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: AbbVie, BMS, Celgene, Novartis

AB0509 AGREEMENT BETWEEN LABIAL BIOPSIES AND THE OMERACT GREY-SCALE ULTRASOUND SCORING SYSTEM FOR SALIVARY GLANDS IN A SINGLE-CENTER COHORT OF PATIENTS WITH SUSPECTED SJÖGREN’S SYNDROME

Background

Ultrasound is a promising non-invasive tool in the evaluation of the salivary glands for parenchymal changes related to Sjögrens Syndrome (SS). The OMERACT Ultrasound Grey-scale (GS) Scoring System for SS has been shown to have good sensitivity and excellent specificity for fulfilling the SS classification criteria, when a GS ≥2 in at least 1 gland was considered indicative of SS (1), however others have suggested pathology in at least 2 glands is required (2). Systematic use of ultrasound might reduce the need for labial biopsies if US findings are in agreement with biopsies.

Objectives

To assess the agreement between labial biopsy results and salivary gland ultrasound findings in patients suspected of SS.

Methods

Patients referred to our department with a suspicion of SS from 2017-2021, scheduled for a diagnostic labial biopsy were recruited. All underwent GS ultrasound of the parotid and submandibular glands bilaterally prior to clinical exam, Schirmer’s test, unstimulated salivary flow, blood samples including autoantibody analysis. Still images of the four glands were scored 0-3 using a previously developed ultrasound atlas (1) of the OMERACT ultrasound scoring system for SS (2,3). All biopsies were evaluated by a pathologist and focus score ≥1 was considered indicative of SS. Two different ultrasound scores for SS were tested: US-score ≥2 in at least 1 gland and US-score ≥2 in at least 2 glands. Descriptive statistics were used. In these analyses, we used labial biopsy as reference standard.

Results

103 patients were included and 44 were clinically diagnosed with SS of which 42 (95%) fulfilled the 2016 ACR/EULAR classification criteria and 33 (75%) had positive labial biopsy. Demographics are shown in Table 1.

Table 1.

Demographics

All patients, n=103Gender, n=females (%)89 (86)Age, mean ± SD55 ± 15.9Symptoms > 2 years, n=patients (%)51 (50)Symptoms < 2 years, ≥ 1 year, n= patients (%)28 (27)Symptoms < 1 year, n= patients (%)24 (23)Biopsy with focus score ≥ 1, n= patients (%)32 (31)US with ≥ 1 gland score ≥ 2, n=patients (%)36 (35)US with ≥2 glands score ≥ 2, n= patients (%)31 (30)SSA positive (%)39 (38)SSB positive (%)9 (9)ANA positive (%)42 (41)Sialometry positive (%)67 (65)Schirmer’s test positive (%)32 (31)

The sensitivity of ultrasound score ≥2 in at least 1 gland was 0.69 and the specificity 0.80. The positive predictive (PPV) and negative predictive values (NPV) were 0.61 and 0.85, respectively. Applying ultrasound score ≥2 in at least 2 glands did not improve specificity (0.83), PPV (0.61) or NPV (0.82) whereas sensitivity dropped to 0.59. The agreement between biopsies and ultrasound for SS is shown Figure 1.

Figure 1

Conclusion

In patients with suspected SS, we found good agreement between US of salivary glands and subsequent labial biopsy. US of salivary glands seems useful in the diagnosis and classification of SS, but labial biopsies may still be needed in select cases.

References

[1]Fana V et al. RMD Open. 2021;7(2):e001516.

[2]Jousse-Joulin S et al. Ann Rheum Dis. 2019;78(7):967-973.

[3]Finzel S et al. Rheumatology (Oxford). 2021 May 14;60(5):2169-2176.

Disclosure of Interests

Viktoria Fana: None declared, Nanna Surlemont Schmidt: None declared, Uffe Møller Døhn: None declared, Simon Krabbe: None declared, Lene Terslev Speakers bureau: Novartis, Pfizer, UCB, Janssen and GE

POS1226 CLINICAL FACTORS ASSOCIATED WITH A POSITIVE SARS-CoV-19 TEST AND WITH FREQUENT TESTING DURING THE COVID-19 PANDEMIC IN >10.000 PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES. RESULTS FROM A NATIONWIDE SURVEY FROM THE DANISH DANBIO REGISTRY

Background

Patients with inflammatory rheumatic diseases (IRD) have used self-isolation and social distancing during the pandemic to avoid SARS-CoV-19 infection (reference). In countries with unlimited and free access to SARS-CoV-19 testing, anxiety or other patient related factors might potentially increase test-frequency.

Objectives

In patients with IRD followed in the nationwide DANBIO registry we aimed to explore clinical factors including self-isolation associated with a) a positive SARS-CoV-19 test result (‘infection’), b) higher frequency of SARS-CoV-19 testing during the first 1½ year of the pandemic.

Methods

In May-June 2020, IRD patients followed in the quality registry, DANBIO (n=36,152), were invited to participate in the voluntary online questionnaire survey ‘You and your rheumatic disease during times with corona-virus’. Patient characteristics, treatment and patient reported outcomes were captured in DANBIO and from the questionnaire. Patients were considered as self-isolating if they agreed to the question: I stay at home and avoid others as much as possible.

After written consent, information on dates and SARS-CoV-19 test results (by PCR, polymerase chain reaction) during follow-up (until Nov 2021 and thus before entry of the Omicron variant) was obtained through linkage to the nationwide laboratory system.

Time to first positive PCR and associated characteristics were explored by multivariable Cox regression analyses with hazard ratios, HR, adjusted for: gender/age-group/ diagnosis/biologic therapy/working/ self-isolation/HAQ/EQ-5D. Day 0 was defined as the date of first positive test in cohort (May-07-2020).

Number of SARS-CoV-19 tests (median (IQR)), and characteristics associated with higher test frequency (upper quartile) was explored with multivariable logistic regression analyses (odds ratios, OR, adjustment like above).

Results

In 10,098 included patients, 2.8% were infected during follow-up (Table 1). Age and HAQ seemed lower in infected (Table 1, Figure 1). In multivariable Cox regression analyses, male gender was associated with higher infection risk (HR 1.38 (1.05;1.80) whereas risk was lower in the age-group 61-80 years (0.60 (0.39;0.92) vs. below 40 years). Other factors were statistically insignificant.

Table 1.Total populationSARS-CoV-19 testsNumber of testsPOSITIVE*NEGATIVE<9≥9Patient number10,098282981674062692Patient %1003977426Female, %66543977228Male, %34443977723Age, yrs, median (IQR)61 (51-70)56 (47-55)61 (51-70)55 (47-61)64 (54-72)Age, strata, yrs< 40969496623840-603898496594161-8049842988515>80247199973DiagnosisAxSpA14644966634RA63452987624PsA16893977030Other6004967931Biologic treatment, yes**38313977228HAQ, median**0.50.3750.50.3750.5EQ-5D, median0.80.80.80.80.8Self-isolating, yes84743977426Working46164965842

Row percentage unless otherwise shown

* At least one positive PCR before Nov 2021

**May 2020

AxSpA: Axial spondyloarthritis, EQ-5D: EuroQol quality of life (5D), HAQ: health assessment questionnaire, IQR: interquartile range, PsA: psoriatic arthritis, RA: rheumatoid arthritis

Median number of PCR tests was 4 (IQR 1-9). In patients with <9 tests, 2.6% were infected whereas for patients with ≥9 tests, 3.2% were infected. Patients with ≥9 tests were younger, more frequently female and working in univariate (Table 1) and adjusted analyses, whereas other characteristics were statistically insignificant (details not shown).

Conclusion

Few patients with IRD were infected during the first 1½ years of the pandemic. Gender and age were associated with infection risk and frequency of testing. Self-isolation and a range of other clinical characteristics had no impact, which to some extent may be due to behavioral differences across age-groups.

References

[1]Glintborg B et al, RMD open, 2021

Disclosure of Interests

Bente Glintborg Grant/research support from: AbbVie, BMS, Pfizer, Dorte Vendelbo Jensen: None declared, Lene Terslev Speakers bureau: Roche, Novartis, Pfizer, UCB, Janssen, Oliver Hendricks Grant/research support from: AbbVie, Novartis, Pfizer, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Celgene, Merck, Novartis, Grant/research support from: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Galapagos, Gilead, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Simon Horskjær Rasmussen: None declared, Mogens Pfeiffer-Jensen: None declared, Thomas Adelsten: None declared, Ada Colic: None declared, Kamilla Danebod: None declared, Malene Kildemand: None declared, Anne Gitte Loft Speakers bureau: AbbVie, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, and UCB, Heidi Lausten Munk: None declared, Jens Kristian Pedersen: None declared, René Østgård Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Eli-Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi and UCB, Grant/research support from: AbbVie, Christian Møller Sørensen: None declared, Niels Steen Krogh: None declared, Jette Nørgaard Agerbo: None declared, Connie Ziegler: None declared, Merete Lund Hetland Grant/research support from: AbbVie, Biogen, BMS, Celtrion, Eli Lilly Denmark A/S, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopis, Sandoz

OP0291 SCORING STRUCTURAL DAMAGE IN RHEUMATOID ARTHRITIS BY ULTRASOUND: RESULTS FROM A DELPHI PROCESS AND WEB-RELIABILITY EXERCISE BY THE OMERACT US WORKING GROUP

Background

Structural damage in rheumatoid arthritis (RA) includes bone erosion, cartilage change, and joint malalignment; historically evaluated with conventional radiography. Ultrasound (US) has been shown to be a valid tool for evaluating both cartilage change and bone erosion.

Objectives

To obtain agreement on definitions and develop semiquantitative scoring systems for assessing structural damage by US and to validate these in a web-based reliability exercise.

Methods

A Delphi survey of statements was prepared by an OMERACT US Working Group task force (USWG) based on a previously published systematic literature review (1) and circulated between group members, including definitions on normal US appearance of joint components, definitions of elementary lesions and scoring systems for bone erosions and joint malalignment. Definitions and a US scoring system for scoring cartilage change were recently developed and validated by the USWG (2) After agreement was achieved (≥75% of grades 4-5 on 1-5 Likert scale) on the statements, still images of metacarpophalangeal and proximal interphalangeal joints 2-5 in healthy controls and in RA patients with varying degrees of pathology were acquired by the USWG members. A dataset of 100 anonymized images, representing various grades of the 3 components of structural damage was created and utilized in 2 rounds of a web-based exercise. Intra- and inter-reader reliability of the scoring systems was assessed by kappa statistics.

Results

19 USWG members needed 4 Delphi rounds to reach agreement on a total of 9 statements. 4/12 statements were approved in the first, 2/6 in the second, 1/5 in the third and 2/2 in the fourth round. Final scoring systems and representative images are shown in Table 1 & Figure 1. 22 members participated in the web-based reliability exercise. The intra-reader reliability was almost perfect for bone erosion (kappa: 0.87) and cartilage change (kappa: 0.83) and substantial for malalignment (kappa of 0.72). The inter-reader reliability was almost perfect for bone erosion (kappa: 0.85), and substantial for cartilage change (kappa: 0.79) and malalignment (0.62).

Table 1.

Final definitions of scoring systems of elementary lesions of structural damage in rheumatoid arthritis

AgreementBone erosionA 4-grade semiquantitative scoring system can be used to score erosions as follows: grade 0. intact cortical bone; grade 1. single small erosion (diameter: ≤2mm); grade 2. single large erosion (diameter: >2mm) or 2 small erosions; grade 3. 2 large erosions or ≥3 erosions, regardless of size. Both longitudinal and transverse scans should be considered, and the largest measure chosen for each erosion.100%Cartilage changeA 3-grade semiquantitative scoring system can be used to grade hyaline cartilage change as follows: grade 0. normal cartilage; grade 1. minimal change: focal thinning or incomplete loss of cartilage; grade 2. severe change: diffuse thinning or complete loss of cartilage.80% (2)MalalignmentA 3-grade semiquantitative scoring system can be used to grade malalignment as follows: 0. normal alignment; 1. subluxation or partial dislocation, where the two bone endings are malaligned so that one bone ending is dislocated from its normal position, but still within the articulation; 2. luxation or total dislocation, where the luxated bone ending moves beyond the articulation and the opposing bone ending. Bone position may be compared with a contralateral or similar intact joint if available.94%Figure 1.

Representative images of the scoring systems for bone erosion (A), cartilage change (B) and malalignment (C)

Conclusion

This first attempt to create a composite US instrument based on scoring systems encompassing all aspects of structural damage, demonstrates that US is a reliable tool for evaluating and scoring bone erosion, cartilage change and malalignment in the finger joints of RA patients.

References

[1]Gessl I, et al. Semin Arthritis Rheum. 2021 Jun;51(3):627-39.

[2]Mandl P, et al. Rheumatology (Oxford). 2019 Oct 1;58(10):1802-11.

Disclosure of Interests

Peter Mandl Speakers bureau: AbbVie, Janssen, Lilly, Novartis, Consultant of: AbbVie, Janssen, Lilly, Novartis, Grant/research support from: AbbVie, BMS, Novartis, Janssen, Lilly, MSD, UCB, Irina Gessl: None declared, Georgios Filippou: None declared, Silvia Sirotti: None declared, Lene Terslev Speakers bureau: Novartis, Pfizer, UCB, Janssen, GE, Carlos Pineda: None declared, Helen Keen Speakers bureau: Roche, AbbVie, Janssen, Consultant of: Sanofi, Marina Backhaus: None declared, David Andrew Bong: None declared, Edoardo Cipolletta: None declared, PAZ COLLADO: None declared, Christian Dejaco Speakers bureau: Roche, AbbVie, Sanofi, Lilly, Pfizer, Novartis, Janssen, Galapagos, Consultant of: Roche, AbbVie, Sanofi, Lilly, Pfizer, Novartis, Janssen, Galapagos, Andrea Delle Sedie Speakers bureau: Abbvie, Amgen, Lilly, MSD, Novartis, UCB, Paid instructor for: Abbvie, Amgen, Lilly, MSD, Novartis, UCB, Consultant of: Abbvie, Amgen, Lilly, MSD, Novartis, UCB, Christina Duftner: None declared, Hilde Berner Hammer: None declared, Annamaria Iagnocco: None declared, Zunaid Karim: None declared, Ingrid Möller Speakers bureau: Bristol-Myers Squibb, Ibsa, Pfizer, Galapagos, Esperanza Naredo Speakers bureau: Abbvie, Pfizer, Lilly, Novartis, Janssen, Celgene GmbH, Paid instructor for: Novartis, Consultant of: Novartis, Lilly, Grant/research support from: Lilly, Pfizer, Wolfgang A. Schmidt: None declared, Marcin Szkudlarek: None declared, Giorgio Tamborrini: None declared, Priscilla C Wong: None declared, Emilio Filippucci Speakers bureau: AbbVie, Amgen, Bristol -Myers Squibb, Janssen-Cilag, Lilly, Novartis, Pfizer, Roche, Union Chimique Belge Pharma, Peter Balint Speakers bureau: Abbvie, Janssen, Lilly, Novartis, Maria-Antonietta D’Agostino: None declared

Training and assessment of musculoskeletal ultrasound and injection skills-a systematic review

OBJECTIVES

To examine how residents are trained and assessed in musculoskeletal ultrasound (MSUS), MSUS-guided and landmark-guided joint aspiration and injection. Additionally, to present the available assessment tools and examine their supporting validity evidence.

METHODS

A systematic search of PubMed, Cochrane Library, and Embase was conducted in accordance with the PRISMA guidelines and studies published from January 1, 2000 to May 31, 2021 were included. Two independent reviewers performed the search and data extraction. The studies were evaluated using the Medical Education Research Quality Instrument (MERSQI).

RESULTS

9,884 articles were screened, and 43 were included; 3 were randomized studies, 21 pre- and post-test studies, 16 descriptive studies, and 3 studies developing assessment tools. The studies used various theoretical training modalities e.g. lectures, anatomical quizzes and e-learning. The practical training models varied from mannequins and cadavers to healthy volunteers and patients. The majority of studies used subjective "comfort level" as assessment, others used practical examination and/or theoretical examination. All training programs increased trainees' self-confidence, theoretical knowledge, and/or practical performance, however few used validated assessment tools to measure the effect. Only one study met the MERSQI high methodical quality cut-off score of 14.

CONCLUSION

The included studies were heterogeneous, and most were of poor methodological quality and not based on contemporary educational theories. This review highlights the need for educational studies using validated theoretical and practical assessment tools to ensure optimal MSUS training and assessment in rheumatology.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.