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.

Prevalence of survey-based criteria for fibromyalgia and impact on hospital burden: a 7 year follow-up study from an outpatient clinic

OBJECTIVES

To evaluate the prevalence of survey-based criteria for fibromyalgia (FM) among newly referred patients in a rheumatic outpatient clinic, and to compare the use of secondary healthcare services between survey-based FM and non-FM cases.

METHOD

Newly referred patients to an outpatient clinic were screened for the fulfilment of the 2011 FM survey criteria during a 6 month period in 2013 in this observational cohort study. Demographic data were obtained at baseline. Patients' medical files were evaluated and comparisons between groups were made regarding the use of hospital healthcare facilities during the 7 year observation period.

RESULTS

Out of 300 invited patients, 248 (83%) completed the questionnaire; 90 patients (36%) fulfilled survey-based criteria for FM at enrolment. FM cases were primarily women (80% vs 54% of non-FM cases), and received more medications (median 4 vs 3 drugs) and public economic support (62% vs 20%). At the 7 year follow-up, crude analyses showed that FM cases had a higher number of hospital courses (median 10 vs 8) and had undergone more invasive procedures (78% vs 60%). Neurologists (42% vs 28%), gastroenterologists (30% vs 13%), endocrinologists (40% vs 21%), pain specialists (13% vs 3%), psychiatrists (20% vs 7%), and abdominal surgeons (43% vs 30%) were consulted more often by FM than by non-FM cases.

CONCLUSION

Fulfilment of FM survey criteria among newly referred patients to a rheumatic outpatient clinic is frequent. Our study findings show that FM continues to present a challenge for healthcare professionals as well as for patients.

RESEARCH HIGHLIGHTS

● Fulfilment of FM survey criteria among newly referred patients to a rheumatic outpatient clinic is frequent.● The burden on the secondary healthcare system for these patients is significant.● This study suggests the need for increased awareness about the diagnosis of FM among certain medical and surgical specialties.

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.

Infliximab biosimilar-to-biosimilar switching in patients with inflammatory rheumatic disease: clinical outcomes in real-world patients from the DANBIO registry

Objective

Successful uptake of biosimilars in rheumatology is limited by lack of real-world evidence regarding effectiveness of biosimilar-to-biosimilar switching. We investigated infliximab biosimilars CT-P13-to-GP1111 switching among patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA).

Methods

Observational cohort study from the DANBIO registry. Patients were classified as originator-naïve or originator-experienced. Retention rates of 1-year GP1111 treatment were explored (Kaplan-Meier). We identified baseline factors (at the time of switch) associated with withdrawal of GP1111 (multivariable Cox-regression analyses with HRs including originator treatment history). Changes in subjective and objective measures of disease activity 4 months before and after the switch were assessed in individual patients.

Results

Of 1605 patients (685 RA, 314 PsA and 606 AxSpA, median disease duration was 9 years, 37% in Clinical Disease Activity Index/Ankylosing Spondylitis Disease Activity Score remission), 1171 were originator-naïve. Retention rates at 1-year were 83% (95% CI: 81% to 85%) and 92% (95% CI: 90% to 95%) for the originator-naïve and originator-experienced, respectively. GP1111 retention rates were higher in originator-experienced compared to originator-naïve with RA (HR=0.4 (95% CI: 0.2 to 0.7)) and PsA (HR=0.2 (95% CI: 0.1 to 0.8)), but not significantly for AxSpA: HR=0.6 (95% CI: 0.3 to 1.2). Lower disease activity was associated with higher retention. Changes in disease activity preswitch and postswitch were close to zero.

Conclusion

This real-world observational study of more than 1600 patients with inflammatory arthritis showed high 1-year retention following a nationwide infliximab biosimilar-to-biosimilar switch. Retention was higher in originator-experienced and in patients with low disease activity, suggesting outcomes to be affected by patient-related rather than drug-related factors.

OP0195 PREVALENCE OF SURVEY-BASED CRITERIA FOR FIBROMYALGIA AND IMPACT ON HOSPITAL BURDEN: A 7 YEARS FOLLOW UP STUDY FROM AN OUTPATIENT CLINIC

Background

The prevalence of Fibromyalgia (FM) among newly referred patients to rheumatic outpatient clinics is unknown. It is well described that FM patients have increased use of the secondary healthcare facilities, however to what extent the presence of FM burdens the different medical specialties in the secondary health care sector is still unknown.

Objectives

To evaluate the prevalence of fulfilment of survey-based criteria for FM (1) among newly referred patients in a rheumatic outpatient clinic and to compare the use of secondary health care services between survey-based FM- and non-FM cases.

Methods

This is an observational cohort study. Newly referred patients with the suspicion of rheumatic inflammatory disease in an outpatient clinic were evaluated for fulfilment of 2011 FM survey criteria during a 6-month period in 2013. Demographic data were obtained at baseline. Seven years later, patients’ medical files were evaluated, and comparisons between groups were made regarding the use of hospital healthcare facilities during the observation period. Results were adjusted for sex, age, and multiplicity.

Results

248 patients of 300 invited (83%) completed the questionnaire; 90 patients (36%) fulfilled FM criteria at enrolment (Figure 1). FM cases were primarily women (80% vs. 54%) and received more public economical support (62% vs. 20%). At 7 years follow up, adjusted results shows that FM cases had higher number of hospital courses (13 vs. 9) and had undergone more invasive procedures (78% vs. 60%), however differences concerning number of diagnoses between groups were small. Neurologists (42% vs. 28%), gastroenterologists (30% vs. 13%), endocrinologists (40% vs. 21%), pain-specialists (13% vs 3%), psychiatrists (20% vs. 7%), and abdominal surgeons (43% vs. 30%) were consulted more often by FM cases than non-FM cases.

Conclusion

Fulfilment of FM survey criteria among newly referred patients with the suspicion of a rheumatic inflammatory disease to a rheumatic outpatient clinic is frequent. The burden to the secondary healthcare system in these patients is significant. The finding of a minimal difference between groups regarding the number of resulting diagnoses underlines that prolonged and excessive use of healthcare services with referral to multiple specialists should be avoided. Our study findings also support that FM continues to present a challenge for healthcare professionals as well as for patients. A timely and coordinated effort across medical specialties, including rheumatologists, could reduce diagnostic delay, facilitate management, and reduce healthcare utilisation in this patient population.

References

[1]Ferrari, R. and A.S. Russell, A Questionnaire Using the Modified 2010 American College of Rheumatology Criteria for Fibromyalgia: Specificity and Sensitivity in Clinical Practice. Journal of Rheumatology, 2013. 40(9): p. 1590-1595.

Table 1.

Highlighting primary baseline data, primary and secondary endpoints, main differences regarding invasive procedures and medical specialists consulted during seven years follow up.

Fibromyalgia, n= 86Non-fibromyalgia, n=151P-value*Age (years), mean (SD)52.5 (13.7)52.8 (18.6)0.432Female, %8054< 0.001Social economic support of any kind, %6220< 0.001Rheumatic inflammatory disease, %28420.028Number of different courses at hospital, Mean (SD)12.7 (0.9)9 (0.6)< 0.001Number of diagnoses, Mean (SD)5 (0.3)4 (0.2)0.003Numbers of admissions to hospital, Mean (SD)2.1 (0.3)1.9 (0.2)0.550Number of Medications, Mean (SD)7.1 (0.5)6.1 (0.3)0.057Number of Pain Medications, Mean (SD)1.6 (0.1)1.2 (0.1)0.004Invasive procedures total, %78600.003Joint surgery other (including arthroscopies), %30170.026Gastroscopy, %3714< 0.001Colonoscopy, %38210.004Psychiatry, %2070.006Abdominal Surgery, %43300.042Pain centre, %1330.015Endocrinology, %40210.003Gastroenterology, %30130.003Neurology, %42280.029

Acknowledgements

Study data were collected using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at OPEN (Open Patient Data Explorative Network), Odense University Hospital, Region of Southern Denmark

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

Diagnostic accuracy of vascular ultrasound in patients with suspected giant cell arteritis (EUREKA): a prospective, multicentre, non-interventional, cohort study

BACKGROUND

Temporal artery biopsy is considered the diagnostic gold standard for giant cell arteritis, despite approximately 39% of patients who are negative for the condition by biopsy subsequently being given a clinical diagnosis of giant cell arteritis. We aimed to assess the diagnostic accuracy of ultrasound examination in patients with suspected giant cell arteritis.

METHODS

In this prospective, multicentre, non-interventional, cohort study (evaluation of ultrasound's role in patients suspected of having extracranial and cranial giant cell arteritis; EUREKA), we consecutively recruited patients aged 50 years or older, with clinically suspected giant cell arteritis from three Danish hospitals (South West Jutland Hospital in Esbjerg, Silkeborg Regional Hospital, and Rigshospitalet, Glostrup). Participants had a bilateral ultrasound of the temporal, facial, common carotid, and axillary arteries. Ultrasounds were done by ultrasonographers who were systematically trained in vascular ultrasound using appropriate equipment and settings. Participants then had a temporal artery biopsy within 7 days of initiation of corticosteroid treatment. A blinded ultrasound expert assessed all ultrasound images. Ultrasound vasculitis was defined in cranial arteries as a homogeneous, hypoechoic, intimamedia complex thickness and a positive compression sign and as a homogeneous intimamedia complex of 1 mm in thickness or wider in the axillary arteries and of 1·5 mm thickness or wider in the common carotid artery. Participants were followed up at 6 months. During this 6 month period, clinicians were able to collect data from all clinical examinations to enable a full clinical diagnosis at 6 months. Clinical diagnosis was based on the expert opinion of the treating rheumatologist. The diagnostic criterion standard was diagnosis confirmed after 6 months of follow-up. We used logistic regression analyses to calculate the odds ratio and 95% CI of ultrasound as a predictor for giant cell arteritis.

FINDINGS

Between April 1, 2014, and July 31, 2017, 118 patients were screened for inclusion, of whom 106 had both ultrasound examinations and an eligible temporal artery biopsy and were included in the intention-to-diagnose population. The mean age was 72·7 years (SD 7·9), 63 (59%) participants were women, and 43 (41%) were men. Temporal artery biopsy was positive in 46 (43%) of 106 patients, and 62 (58%) of 106 patients had a clinically confirmed diagnosis of giant cell arteritis at 6 months (temporal artery biopsy sensitivity 74% [95% CI 62-84], specificity 100% [95% CI 92-100]). Cranial artery ultrasound was positive in all patients who had a positive temporal artery biopsy, and seven (58%) of 12 patients who were positive by ultrasound and negative by temporal artery biopsy were confirmed to have large-vessel giant cell arteritis via other imaging methods. The sensitivity of ultrasound diagnosis of giant cell arteritis was 94% (84-98) and specificity was 84% (70-93). Logistic regression analysis confirmed that ultrasound was the strongest baseline predictor for a clinically confirmed diagnosis of giant cell arteritis at 6 months (crude odds ratio 76·6 [95% CI 21·0-280·0]; adjusted for sex and age 141·0 [27·0-743·0]).

INTERPRETATION

Vascular ultrasound might effectively replace temporal artery biopsy as a first-line diagnostic method in patients suspected of having giant cell arteritis when done by systematically trained ultrasonographers using appropriate equipment and settings.

FUNDING

The Institute for Regional Research at Hospital of Southwest Jutland, Esbjerg, Denmark.

Development of a new ultrasound scoring system to evaluate glandular inflammation in Sjögren's syndrome: an OMERACT reliability exercise

OBJECTIVE

The aim of this exercise from the OMERACT ultrasound subgroup on Sjögren's syndrome (pSS) was to develop and assess the reliability of a consensus-based semiquantitative colour Doppler (CD) ultrasound scoring system for pathologic salivary gland vascularization in patients with pSS.

METHODS

Using the Delphi method a CD semiquantitative scoring system for vascularization of bilateral parotid and submandibular glands was developed and tested in static images and on patients (9 pSS patients and 9 sonographers). Intra-reader and inter-reader reliability of grading the salivary glands were computed by weighted Cohen and Light's kappa (κ) analysis, respectively.

RESULTS

The consensus-based semiquantitative score was: Grade 0, no visible vascular signals; Grade 1, focal, dispersed vascular signals; Grade 2, diffuse vascular signals detected in < 50% of the gland; Grade 3, diffuse vascular signals in > 50% of the gland. In static images, the intra- and inter-reader reliability showed excellent κ values (95% confidence interval) = 0.90 (0.87-0.93) and 0.80 (0.74-0.84), respectively) for all four salivary glands together. In patients, the intra- and inter-reader reliability for all four salivary glands together was κ  = 0.84 (0.73-0.92) and 0.70 (0.64-0.76), respectively.

CONCLUSION

The consensus-based CD ultrasound scoring for the evaluation of salivary gland vascularization in pSS showed a good inter-reader reliability and excellent intra-reader reliability in static images and in patients. The clinical application of the developed scoring system should be tested in clinical settings.

Musculoskeletal pain in psoriasis - relation to inflammation and additional value of ultrasound in psoriatic arthritis classification

OBJECTIVE

To investigate and compare clinical features and ultrasound signs of inflammation in joints and entheses in patients with psoriasis (PsO) with and without musculoskeletal pain, and the additional value of ultrasound in classification of psoriatic arthritis (PsA). Furthermore, to explore the association between such findings and patient-reported outcomes (PROs) and the performance of screening-questionnaires for identifying patients with PsA.

METHODS

Patients with PsO (n = 126) recruited from a nationwide survey were evaluated at one of four rheumatology departments. The evaluation included clinical examination, laboratory tests, radiography, greyscale (GS) and colour Doppler (CD) ultrasound of 48 joints and 12 entheses, PROs, and four screening-questionnaires for PsA. Patients were classified with Classification for PsA (CASPAR), ultrasound-modified CASPAR, and ultrasound-only criteria.

RESULTS

When subgroups of self-reported pain (63%), no pain (29%) and diagnosed PsA (9%) were compared, patients with pain had higher tenderness-related clinical scores (tender joints, entheses and fibromyalgia points) and ultrasound GS sum-scores, compared with 'no pain' patients. PROs were negligibly-moderately correlated with pain-related clinical scores (Spearman's rho = 0.11-0.59, all patients), and negligibly-weakly with ultrasound sum-scores (rho = 0.01-0.34). More patients could be classified as PsA when ultrasound synovitis/enthesitis was included as entry criterion (ultrasound-modified CASPAR, 66% of all patients) compared with conventional CASPAR (35%) or ultrasound-only criteria (52%). Sensitivities of screening-questionnaires were low for fulfilment of CASPAR (0.23-0.66), ultrasound-modified CASPAR (0.17-0.57), and ultrasound-only (0.20-0.57) criteria.

CONCLUSION

Self-reported pain in PsO is related to ultrasound inflammation. Ultrasound-modified CASPAR criteria identified almost twice as many patients as conventional CASPAR criteria. Screening-questionnaires showed limited value.

The fast-track outpatient clinic significantly decreases hospitalisation rates among polymyalgia rheumatica patients

Objectives

This study aimed to investigate the hospitalisation rates and the reasons for hospitalisation in patients with polymyalgia rheumatica (PMR). Furthermore, it aimed to clarify the impact of a newly established Fast Track Clinic (FTC) approach on hospitalisation rates in connection with PMR diagnosis.

Methods

Patients diagnosed with PMR at South-West Jutland Hospital, Denmark, between 2013 and 2018 were included retrospectively. Only patients fulfilling the 2012 EULAR/ACR classification criteria were included in our cohort. An FTC for patients suspected of having PMR was established in the rheumatologic department of South-West Jutland Hospital in January 2018.

Results

Over 6 years (2013 to 2017), 254 patients were diagnosed with PMR, 56 of them while hospitalised. Hospitalised patients were more likely to have a higher initial CRP mean ± standard deviation (SD) 99.53 ± 59.36 vs 45.82 ± 36.96 mg/lt (p <  0.0001) and a shorter duration of symptoms (p = 0.0018). After implementing the FTC, a significant decrease in hospitalisation rates (from 20.4% to 3,5%) and inpatient days of care (mean ± SD 4.15 ± 3.1 vs 1 ± 0) were observed. No differences between the two groups were observed regarding clinical symptoms, laboratory values and initial prednisolone dose.

Conclusion

A substantial number of patients are hospitalised in connection with the PMR diagnosis. The FTC approach can decrease the hospitalisation rates significantly among these patients.

Trial registration

Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-021-00210-6.

Vascular ultrasound for the diagnosis of giant cell arteritis: a reliability and agreement study based on a standardised training programme

Objective

To evaluate the impact of a standardised training programme including equipment adjustment for experienced musculoskeletal ultrasonographers without previous experience in vascular ultrasound (US) on the reliability of US in the diagnosis of giant cell arteritis (GCA).

Methods

In this prospective, non-interventional observational cohort study, patients suspected of GCA were evaluated by US by one of five rheumatologists with long-standing experience in musculoskeletal US (>8 years), trained using a standardised training programme including equipment adjustment. Images of cranial and large vessels were subsequently evaluated first by the performing ultrasonographer and thereafter by a blinded external expert (gold standard).

Results

In three Danish centres, 112 patients suspected of GCA were included. According to the external expert, vasculitis changes were seen in 66 patients, in 45 of them with only cranial involvement, in 14 with both cranial and large vessel involvement, while in seven patients isolated large vessel vasculitis was found. The reliability was excellent between the local ultrasonographer and the US expert for the overall GCA diagnosis regarding the diagnosis of cranial and for large vessel GCA, with an interobserver agreement of 95–96%, mean kappa values of 0.88–0.92 (95% CI 0.78 to 0.99). Excellent reliability (mean kappa 0.86–1.00) was also found for the US examination of the individual arteries (temporal, facial, common carotid and axillary).

Conclusion

The US training programme resulted in excellent agreement between trainees and an expert in patients suspected of GCA and may thus be applicable for implementation of vascular US in clinical practice.

Diagnosing Giant Cell Arteritis: A Comprehensive Practical Guide for the Practicing Rheumatologist

Giant cell arteritis (GCA) is the most common large vessel vasculitis in the elderly population. In recent years, advanced imaging has changed the way GCA can be diagnosed in many locations. The GCA fast-track clinic (FTC) approach combined with ultrasound (US) examination allows prompt treatment and diagnosis with high certainty. FTCs have been shown to improve prognosis while being cost effective. However, all diagnostic modalities are highly operator dependent, and in many locations expertise in advanced imaging may not be available. In this paper, we review the current evidence on GCA diagnostics and propose a simple algorithm for diagnosing GCA for use by rheumatologists not working in specialist centres.

OMERACT definition and reliability assessment of chronic ultrasound lesions of the axillary artery in giant cell arteritis

OBJECTIVES

To define chronic ultrasound lesions of the axillary artery (AA) in long-standing giant cell arteritis (GCA) and to evaluate the reliability of the new ultrasound definition in a web-based exercise.

METHODS

A structured Delphi, involving an expert panel of the Large Vessel Vasculitis subgroup of the Outcome Measures in Rheumatology (OMERACT) Ultrasound Working Group was carried out. The reliability of the new definition was tested in a 2-round web-based exercise involving 23 experts and using 50 still images each from AA of long-standing and acute GCA patients, as well as 50 images from healthy individuals.

RESULTS

The final OMERACT ultrasound definition of chronic changes was based on measurement and appearance of the intima-media complex. The overall reliability of the new definition for chronic ultrasound changes in longstanding GCA of the AA was good to excellent with Light's kappa values of 0.79-0.80 for inter-reader reliability and mean Light's-kappa of 0.88 for intra-reader reliability. The mean inter-rater and intra-rater agreements were 86-87% and 92%, respectively. Good reliabilities were observed comparing the vessels with longstanding versus acute GCA with a mean agreement and kappa values of 81% and 0.63, respectively.

CONCLUSION

The new OMERACT ultrasound definition for chronic vasculitis of the AA in GCA revealed a good to excellent inter- and intra-reader reliability in a web-based exercise of experts.

Comparative effectiveness of two adalimumab biosimilars in 1318 real-world patients with inflammatory rheumatic disease mandated to switch from originator adalimumab: nationwide observational study emulating a randomised clinical trial

OBJECTIVES

In 2018, a nationwide mandatory switch from originator to biosimilar adalimumab was conducted in Denmark. The available biosimilar was GP2017 (Hyrimoz) in Eastern regions and SB5 (Imraldi) in Western regions. We aimed to assess the comparative effectiveness of GP2017 versus SB5 in patients with rheumatoid arthritis (RA)/psoriatic arthritis (PsA)/axial spondyloarthritis (AxSpA).

METHODS

Observational cohort study based on the DANBIO registry with geographical cluster pseudo-randomisation, analysed by emulating a randomised clinical trial. Main outcome was adjusted 1-year treatment retention (Cox regression). Furthermore, 6 months' remission rates (logistic regression), reasons for withdrawal and back-switching to originator were investigated (overall and stratified by indication).

RESULTS

Overall, of 1570 eligible patients, 1318 switched and were included (467 RA/321 PsA/530 AxSpA); 623 (47%) switched to GP2017, 695 (53%) to SB5. Baseline characteristics of the two clusters were largely similar, but some differences in registration practice were observed. The combined 1-year retention rate for the two biosimilars was 89.5%. Compared with SB5, estimated risk of withdrawal for GP2017 was lower (HR 0.60; 95% CI 0.42 to 0.86) and 6 months' remission rate was higher (OR 1.72; 95% CI 1.25 to 2.37). Stratified analyses gave similar results (statistically significant for RA). During 1 year, 8.5% and 12.9% withdrew GP2017 and SB5, respectively (primarily lack of effect and adverse events), of whom 48 patients (3.6%) back-switched.

CONCLUSION

This head-to-head comparison of GP2017 versus SB5 following a mandatory switch from the originator indicated differences in effectiveness in routine care. This may reflect a true difference, but other explanations, for example, differences in excipients, differences between clusters and residual confounding cannot be ruled out.

SAT0558 THE IMPACT OF A STANDARDIZED TRAINING PROGRAM FOR IMPROVING THE RELIABILITY AND AGREEMENT – A STUDY OF VASCULAR ULTRASOUND FOR DIAGNOSING GIANT CELL ARTERITIS IN DENMARK

Background:

Due to a high level of evidence of good test performance, accessibility, minimal invasiveness, low cost, and good overall performance, EULAR recommends ultrasound (US) of the temporal and axillary arteries as primary diagnostic imaging test in patients suspected of Giant Cell Arteritis (GCA) (1).

Despite the growing body of evidence supporting the utility of US in GCA, standardized training programs and their impact on reliability are lacking(1). In TABUL study (2), the only US study published to date using a standardised US training program, the interobserver agreement by 12 different sonographers was only moderate, illustrating the challenges presented in the education for US in GCA.

Objectives:

To evaluate the impact of a standardized training program including equipment adjustment on the agreement and reliability of US in the diagnosis of GCA for experienced musculoskeletal (MSK)ultrasonographers, without previous experience on vascular US.

Methods:

Five rheumatologists with long-standing experience in MSK US were trained by a standardized training program including equipment adjustment (Box 1) prior to a prospective, non-interventional observational study in patients suspected having GCA.The rheumatologist performing the US subsequently evaluated the images blinded to the patients data. Thereafter the images were evaluated by a blinded external expert (i.e. considered the gold standard).

Results:

In three Danish centers 112 patients were included, 59% females, mean age 72.4 (SD) 7.9 years and median CRP 55 (IQR 21-100)mg/l. Median duration of prednisolone treatment prior to US examination was 0 (IQR 0 to 1) days. 92% of the patients reported a newly emerged localized headache.

The reliability between the performing ultrasonographer and the US expert for the overall GCA diagnosis, as for the diagnosis of cranial (c-GCA) and large-vessel GCA (Lv-GCA) was excellent. In addition, excellent reliability was also found for the US examination of all examined arteries (Table 1). According to the US expert, vasculitis changes were found in 66 patients with the pathological findings distributed as presented in table 1.

Table 1VariablesPathological findings (%)Interobserver agreement (%)Interobserver ReliabilityKappa Coefficient95% Confidence LimitsUS positive for GCA59%96%0.930.85-0.9966/112US positive for cGCA53%95%0.890.81-0.9859/112US positive for Lv-GCA19%96%0.890.78-0.99521/112Halo sign TA, all51%96%0.910.83-0.99segments57/112Compression sign TA,48%94%0.890.80-0.9851/107all segmentsHalo sign FA20%96%0.870.75-0.9823/112Compression sign16%96%0.860.73-0.99FA17/107Halo sign AA18%97%0.910.81-1.0020/112Halo sign AC4%100%1.001.00-1.006/11

TA: Temporal; FA: Facial; AA: Axillary; AC: common Carotid, artery

Conclusion:

Our training program resulted in excellent reliability of US findings in patients suspected of having GCA and for the final diagnosis. The training program could be used when implementing vascular US in clinical practice.

Box 1

References:

[1]Dejaco C et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Ann Rheum Dis 2018;77:636

[2]Luqmani R et al. The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis: a diagnostic accuracy and cost-effectiveness study Health Technol Assess 2016;20:1_238

Disclosure of Interests:

stavros chrysidis: None declared, Lene Terslev Speakers bureau: LT declares speakers fees from Roche, MSD, BMS, Pfizer, AbbVie, Novartis, and Janssen., Robin Christensen: None declared, Ulrich Fredberg: None declared, Knud Larsen: None declared, Tove Lorenzen: None declared, Uffe Møller Døhn: None declared, Andreas Diamandopoulos: None declared

FRI0197 THE DIAGNOSTIC ACCURACY OF VASCULAR ULTRASOUND IN PATIENTS SUSPECTED OF GCA: A DANISH MULTICENTRE PROSPECTIVE COHORT STUDY

Background:

Giant Cell Arteritis (GCA) is one of the most common systemic vasculitis. Temporal artery biopsy (TAB) has been the standard test to confirm the diagnosis of GCA. However, TAB has a lower sensitivity than clinical diagnosis and up to 44% of biopsy-negative patients are clinically diagnosed as having GCA.

In a recent meta-analysis of the diagnostic performance of ultrasound (US) in GCA the sensitivity was 77 % (1). The included studies were performed by expert groups in single centres. In the to date only multicentre study (TABUL) investigating the diagnostic accuracy of US compared to clinical diagnosis after 6 months the sensitivity was lower (54%) (2)

Objectives:

To evaluate the diagnostic accuracy of vascular US compared to TAB in a multicentre study.

Methods:

In three Danish centres patients suspected for GCA were included during a period of two years. At baseline, clinical and laboratory data were collected and vascular US of temporal, facial, common carotid and axillary artery were performed. The US examinations were performed with high frequency transducers (15-18 MHZ) and followed by a TAB. All ultrasongraphers had participated in the same standardized US educational program and were blinded to clinical and laboratory data. An external expert blinded to clinical and laboratory data evaluated all images and made the final US diagnosis.

A positive sign for vasculitis in cranial arteries was defined as a hypoechoic intima media complex (IMC) thickening (halo sign) and a positive compression sign. A homogeneous IMC increased thickness in axillary artery of ≥1mm and in common carotid artery ≥1.5mm was defined as vasculitis.

The consultant rheumatologist’s diagnosis at 6 months after initial presentation was considered as the reference standard for the diagnosis of GCA.

Results:

During the recruitment period, 112 patients were included, 59% females, mean (SD) age 72.4(7.9) years, among which 91(81.3%) fulfilled the ACR 1990 classification criteria for GCA. 92% of the patients reported a newly emerged localized headache, while 49 (43.8%) experienced polymyalgia rheumatic symptoms.

TAB was positive in 46(41.1%) and inconclusive in 6 patients, who were excluded from the analysis. Mean (SD) duration of glucocorticoid therapy prior to US and TAB was 0.91(1.55) and 4.02(2.61) days, respectively. In 62 patients, the final diagnosis was GCA.

In all patients with a positive TAB, the US of the temporal artery was also positive for GCA. Of 19 cases with positive US and negative TAB, 12 were clinically diagnosed with GCA of whom 6 had isolated large vessel involvement on US. Among 41 patients with both negative US and TAB, 4 were clinically diagnosed with GCA (Box 1)

US had a sensitivity of 93% and specificity of 84% for the diagnosis of GCA, while the sensitivity for TAB was lower (74%) with a specificity of 100%. For the diagnosis of GCA, US had a PPV of 89.2 % and a NPV of 90.2%, while for TAB the PPV was 100% and the NPV 73.3%.

Conclusion:

US evaluation of the temporal, facial and selected supraaortic arteries performed by trained ultrasonographers can replace biopsy in the diagnosis of GCA.

Box.1

References:

[1]Duftner C, Dejaco C, et al. Imaging in diagnosis, outcome prediction and monitoring of large vessel vasculitis: a systematic literature review and metaanalysis informing the EULAR recommendations. RMD Open 2018;4:e000612.

[2]Luqmani R et al. The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study. Health Technol Assess 2016;20:1_238.

Disclosure of Interests:

stavros chrysidis: None declared, Uffe Møller Døhn: None declared, Lene Terslev Speakers bureau: LT declares speakers fees from Roche, MSD, BMS, Pfizer, AbbVie, Novartis, and Janssen., Ulrich Fredberg: None declared, Tove Lorenzen: None declared, Robin Christensen: None declared, Per Søndergaard: None declared, Jakob Matthisson: None declared, Knud Larsen: None declared, Andreas Diamandopoulos: None declared

AB0516 INITIAL TREATMENT OF POLYMYALGIA RHEUMATICA PATIENTS: COMPARISONS BETWEEN GENERAL PRACTITIONERS AND THE RHEUMATOLOGIST

Background:

Polymyalgia rheumatica (PMR) is the most common inflammatory rheumatic disease at persons > 50 years of age. It is clinically characterized by pain and stiffness in the neck, proximal shoulder, and hip girdle. (1)Glucocorticoid (GC) is the cornerstone of PMR treatment; the use is associated with potentially severe side effects (3).According to EULAR-ACR recommendations for the management of PMR, treatment should be individualized using the minimum effective GC dose. (2)

An initial prednisolone dose of > 15mg is associated with significantly higher risk for GCs related side effects (1) and GC doses higher than 25 mg/day are discouraged because of the high risk of adverse events; furthermore, there is no evidence that such doses are more effective than lower doses (2,3).

In most countries, the vast majority of PMR patients are diagnosed and managed primarily by their General Practitioner (GP) (4)

Objectives:

To compare the initial GC dose for PMR patients diagnosed by their GP versus an outpatient rheumatological clinic in Denmark.

Methods:

All patients with the diagnosis of PMR in South-West Jutland Hospital, Denmark at the period of 2013 to 2018 were identified from an electronic register.

Patients with an already known rheumatic disease before the diagnosis of PMR, GCA symptoms at the diagnosis time or hospitalized at the diagnostic time were excluded.

Clinical and paraclinical data were collected from the patient’s electronic journal.

Results:

In a period of 6 years, 342 patients with PMR were identified. Of 342 patients 83 were diagnosed by their GP. No significant differences were found regarding demographical, clinical and paraclinical baseline characteristics between the two groups. No differences were identified regarding the treatment response. However the initial prednisone dose in patients diagnosed by the GP’s was significantly higher (p<0, 00001) compared to the rheumatological outpatient clinic (Table 1) with an initial dose of ≥25mg at over 50% of newly diagnosed cases (45 patients).

Table 1.Diagnosed by GPsN 83Diagnosed by the rheumatological outpatient clinicN 259P valuesAge (years) ± SD70,2 ± 8,270,58± 7,5n.s*Gender-female(%)62,6%56,7%n.s*Duration of symptoms (weeks)± SD12,34 ± 1012,9 ± 13,4n.s*Age over 50 %98,8%99,6%n.sBilateral shoulder pain (%)95,1%96,5%n.sAbnormal CP and/or SR (%)87,8%94,2%n.s*CRP (mg/lt) ± SD36,8 ± 32,245,8± 36,8n.s*SR(mm/hour) ± SD50,1±26,555,1±23,7n.s*Morning stiffness87,9%91%n.s*Hip pain or limited range of motion66,2%70,4%n.s*RF and aCCP negative %87,9%90,2%n.s*Absence of other joint involvement79,5%71%n.s*Initial prednisolone dose(mg) ± SD25,65 ± 12,116,4±4,5<0,0001Response to treatment93,9%94,1%n.s

*non-significant

Conclusion:

Our study shows that the initial GC dose is significantly higher for PMR patients diagnosed by GPs which may lead to a higher risk of GC related side effects.

References:

[1]Camellino D, Dejaco C. Update on treatment of polymyalgia rheumatica Reumatismo. 2018 Mar 27;70(1):59-66. doi: 10.4081/reumatismo.2018.1062.

[2]Dejaco C, Singh YP, Perel P, et al. 2015 recommendations for the management of polymyalgia rheumatica: A European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis. 2015; 74: 1799-807

[3]Dejaco C, Singh YP, Perel P, et al. Current evidence for therapeutic interventions and prognostic factors in polymyalgia rheumatica: a systematic literature review informing the 2015 European League Against Rheumatism/ American College of Rheumatology recommendations for the management of po. Ann Rheum Dis. 2015; 74: 1808-17.

[4]Helliwell T, Muller S, Hider SL, Zwierska I, Lawton S, Richardson J, Mallen C. Challenges of diagnosing and managing polymyalgia rheumatica: a multi methods study in UK general practice. Br J Gen Pract. 2018 Nov;68(676):e783-e793. doi: 10.3399/bjgp18X699557.

Disclosure of Interests:

None declared

Video clip assessment of a salivary gland ultrasound scoring system in Sjögren's syndrome using consensual definitions: an OMERACT ultrasound working group reliability exercise

OBJECTIVE

To develop ultrasound (US) definitions and a US novel scoring system for major salivary gland (SG) lesions in patients with primary Sjögren's syndrome (pSS) and to test their intrareader and inter-reader reliability using US video clips.

METHODS

Twenty-five rheumatologists were subjected to a three-round, web-based Delphi process in order to agree on (1) definitions and scanning procedure of salivary gland ultrasonography (SGUS): parotid, submandibular and sublingual glands (PG, SMG and SLG); (2) definitions for the elementary SGUS lesions in patients with Sjögren's syndrome; (3) scoring system for grading changes. The experts rated the statements on a 1-5 Likert scale. In the second step, SGUS video clips of patients with pSS and non-pSS sicca cases were collected containing various spectrums of disease severity followed by an intrareader and inter-reader reliability exercise. Each video clip was evaluated according to the agreed definitions.

RESULTS

Consensual definitions were developed after three Delphi rounds. Among the three selected SGs, US assessment of PGs and SMGs was agreed on. Agreement was reached to score only greyscale lesions and to focus on anechoic/hypoechoic foci in a semiquantitative matter or, if not possible on a qualitatively (present/absent) evaluation of fatty or fibrous lesions. Intrareader reliability for detecting and scoring these lesions was excellent (Cohen's kappa 0.81) and inter-reader reliability was good (Light's kappa 0.66).

CONCLUSION

New definitions for developing a novel semiquantitative US score in patients with pSS were developed and tested on video clips. Inter-reader and intrareader reliabilities were good and excellent, respectively.

To switch or not to switch: results of a nationwide guideline of mandatory switching from originator to biosimilar etanercept. One-year treatment outcomes in 2061 patients with inflammatory arthritis from the DANBIO registry

OBJECTIVES

Real-world evidence on effectiveness of switching to biosimila r etanercept is scarce. In Denmark, a nationwide guideline of mandatory switch from 50 mg originator (ETA) to biosimilar (SB4) etanercept was issued for patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA) in 2016. Clinical characteristics and treatment outcomes were studied in ETA-treated patients, who switched to SB4 (switchers) or maintained ETA (non-switchers). Retention rates were compared with that of a historic cohort of ETA-treated patients. Switchers who resumed ETA treatment (back-switchers) were characterised.

METHODS

Observational cohort study based on the DANBIO registry. Treatment retention was explored by Kaplan-Meier plots and Cox regression (crude, adjusted).

RESULTS

1621 (79%) of 2061 ETA-treated patients switched to SB4. Disease activity was unchanged 3 months' preswitch/postswitch. Non-switchers often received 25 mg ETA (ETA 25 mg pens/syringes and powder solution were still available). One-year adjusted retention rates were: non-switchers: 77% (95% CI: 72% to 82%)/switchers: 83% (79% to 87%)/historic cohort: 90% (88% to 92%). Patients not in remission had lower retention rates than patients in remission, both in switchers (crude HR 1.7 (1.3 to 2.2)) and non-switchers (2.4 (1.7 to 3.6)). During follow-up, 120 patients (7% of switchers) back-switched to ETA. Back-switchers' clinical characteristics were similar to switchers, and reasons for SB4 withdrawal were mainly subjective.

CONCLUSION

Seventy-nine per cent of patients switched from ETA to SB4. After 1 year, adjusted treatment retention rates were lower in switchers versus the historic ETA cohort, but higher than in non-switchers. Withdrawal was more common in patients not in remission. The results suggest that switch outcomes in routine care are affected by patient-related factors and non-specific drug effects.

Assessing Vasculitis in Giant Cell Arteritis by Ultrasound: Results of OMERACT Patient-based Reliability Exercises

Objective.

To test the reliability of Outcome Measures in Rheumatology Clinical Trials (OMERACT) consensus-based ultrasound definitions for normal and vasculitic temporal and axillary arteries in patients with giant cell arteritis (GCA) and in controls.

Methods.

A preliminary 1-day meeting and a full 3-day meeting fulfilling OMERACT Ultrasound Group guidelines were held. Temporal and axillary arteries were examined at 2 timepoints by 12 sonographers on 4 patients with GCA and 2 controls. The aim was to test inter- and intrareader reliability for normal findings, halo sign, and compression sign. In both meetings, patients had established GCA. Pathology was more recent in the full meeting, which was preceded by 6 h of training. Scanning time was 15–20 min instead of 10–13 min.

Results.

In the preliminary exercise, interreader reliabilities were fair to moderate for the overall diagnosis of GCA (Light κ 0.29–0.51), and poor to fair for identifying vasculitis in the respective anatomical segments (Light κ 0.02–0.46). Intrareader reliabilities were moderate (Cohen κ 0.32–0.64). In the main exercise, interreader reliability was good to excellent (Light κ 0.76–0.86) for the overall diagnosis of GCA, and moderate to good (Light κ 0.46–0.71) for identifying vasculitis in the respective anatomical segments. Intrareader reliability was excellent for diagnosis of GCA (Cohen κ 0.91) and good (Cohen κ 0.71–0.80) for the anatomical segments.

Conclusion.

OMERACT-derived definitions of halo and compression signs of temporal and axillary arteries are reliable in recent-onset GCA if experienced sonographers (> 300 examinations) have 15–20 min for a standardized examination with prior training and apply > 15 MHz probes.

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

Objectives

To define the elementary ultrasound (US) lesions in giant cell arteritis (GCA) and to evaluate the reliability of the assessment of US lesions according to these definitions in a web-based reliability exercise.

Methods

Potential definitions of normal and abnormal US findings of temporal and extracranial large arteries were retrieved by a systematic literature review. As a subsequent step, a structured Delphi exercise was conducted involving an expert panel of the Outcome Measures in Rheumatology (OMERACT) US Large Vessel Vasculitis Group to agree definitions of normal US appearance and key elementary US lesions of vasculitis of temporal and extracranial large arteries. The reliability of these definitions on normal and abnormal blood vessels was tested on 150 still images and videos in a web-based reliability exercise.

Results

Twenty-four experts participated in both Delphi rounds. From originally 25 statements, nine definitions were obtained for normal appearance, vasculitis and arteriosclerosis of cranial and extracranial vessels. The ‘halo’ and ‘compression’ signs were the key US lesions in GCA. The reliability of the definitions for normal temporal and axillary arteries, the ‘halo’ sign and the ‘compression’ sign was excellent with inter-rater agreements of 91–99% and mean kappa values of 0.83–0.98 for both inter-rater and intra-rater reliabilities of all 25 experts.

Conclusions

The ‘halo’ and the ‘compression’ signs are regarded as the most important US abnormalities for GCA. The inter-rater and intra-rater agreement of the new OMERACT definitions for US lesions in GCA was excellent.

Polymyalgia rheumatica and giant cell arteritis-three challenges-consequences of the vasculitis process, osteoporosis, and malignancy: A prospective cohort study protocol

INTRODUCTION

Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are common inflammatory conditions. The diagnosis of PMR/GCA poses many challenges since there are no specific diagnostic tests. Recent literature emphasizes the ability of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) to assess global disease activity in inflammatory diseases. 18F-FDG PET/CT may lead to the diagnosis at an earlier stage than conventional imaging and may also assess response to therapy. With respect to the management of PMR/GCA, there are 3 significant areas of concern as follows: vasculitis process/vascular stiffness, malignancy, and osteoporosis.

METHODS AND ANALYSIS

All patients with suspected PMR/GCR referred to the Rheumatology section of Medicine Department at Svendborg Hospital, Denmark. The 4 separate studies in the current protocol focus on: the association of clinical picture of PMR/GCA with PET findings; the validity of 18F-FDG PET/CT scan for diagnosis of PMR/GCA compared with temporal artery biopsy; the prevalence of newly diagnosed malignancies in patients with PMR/GCA, or PMR-like syndrome, with the focus on diagnostic accuracy of 18F-FDG PET/CT scan compared with conventional workup (ie, chest X-ray/abdominal ultrasound); and the impact of disease process, and also steroid treatment on bone mineral density, body composition, and vasculitis/vascular stiffness in PMR/GCA patients.

ETHICS AND DISSEMINATION

The study has been approved by the Regional Ethics Committee of the Region of Southern Denmark (identification number: S-20160098) and Danish Data Protection Agency (J.nr 16/40522). Results of the study will be disseminated via publications in peer-reviewed journals, and presentation at national and international conferences.

A nationwide non-medical switch from originator infliximab to biosimilar CT-P13 in 802 patients with inflammatory arthritis: 1-year clinical outcomes from the DANBIO registry

OBJECTIVES

According to guidelines, a nationwide non-medical switch from originator (INX, Remicade) to biosimilar infliximab (Remsima, CT-P13) was conducted in Danish patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA). We investigated disease activity before/after switching and retention rates in the DANBIO registry.

METHODS

Disease activities 3 months before and after switch and changes over time were calculated. Flare was defined as change in 28 Joint Disease Activity Score (∆DAS28) ≥1.2 (RA/PsA) or Ankylosing Spondylitis Disease Activity Score (∆ASDAS) ≥1.3 (AxSpA). Crude and adjusted retention rates were compared with a historic cohort of INX-treated patients.

RESULTS

Eight hundred and two patients switched (403 RA/120 PsA/279 AxSpA; 51% women, age (median (IQR): 55 (44-66)) years). Follow-up was 413 (339-442) days. Prior INX treatment duration was 6.8 (4.3-9.5) years. Disease activities were similar 3 months before/after switch. Crude 1-year CT-P13 retention rate (84.1 (95% CI 81.3 to 86.5)) was similar to the historic IFX cohort (86.2 (95% CI 84.0 to 88.0), p=0.22). The adjusted absolute retention rates were 83.4 (95% CI 80.8 to 86.2) and 86.8% (95% CI 84.8 to 88.8), respectively (p=0.03). In total 132 patients withdrew (lack of effect: 71/132=54%, adverse events: 37/132=28%). Patients with previous INX treatment duration >5 years had longer CT-P13 retention.

CONCLUSION

In 802 arthritis patients treated with INX for median >6 years, a nationwide non-medical switch to CT-P13 had no negative impact on disease activity. Adjusted 1-year CT-P13 retention rate was slightly lower than for INX in a historic cohort.

Impact of tobacco smoking on response to tumour necrosis factor-alpha inhibitor treatment in patients with ankylosing spondylitis: results from the Danish nationwide DANBIO registry

OBJECTIVES

To investigate the association between tobacco smoking and disease activity, treatment adherence and treatment responses in patients with AS treated with their first tumour necrosis factor-alpha inhibitor (TNFi) therapy in routine care.

METHODS

Observational cohort study based on the Danish nationwide DANBIO registry. Kaplan-Meier plots, Cox and logistic regression analyses by smoking status (current/never/previous) were calculated for treatment adherence and BASDAI 50%/20 mm-response. Additional stratified analyses were performed for gender and TNFi-type.

RESULTS

Of 1576 AS patients included in the study, 1425(90%) had known smoking status (current/never/previous: 43%/41%/16%). The median follow-up time was 2.02 years (IQR 0.69-5.01). At baseline, current smokers compared with never smokers had longer disease duration (4 years (1-12)/2 years (0-10)), higher BASDAI (61 mm (47-73)/58 mm (44-70)), BASFI (53 mm (35-69)/46 mm (31-66)) and BASMI (40 mm (20-60)/30 mm (10-50)) scores (all P < 0.01). Current and previous smokers had shorter treatment adherence than never smokers (current: 2.30 years (1.81-2.79) (median (95% CI)); previous: 2.48 years (1.56-3.40), never: 4.12 years (3.29-4.95)), P < 0.0001). Similar results were found in multivariate analyses (current versus never smokers, HR 1.41 (95% CI 1.21-1.65), P < 0.001), most pronounced among men. Current smokers had poorer 6 months' BASDAI50%/20 mm-response rate than never smokers (42%/58%, P < 0.001). In multivariate analyses, current smokers had lower odds of achieving BASDAI50%/20 mm-response than never smokers, both overall (OR 0.48 (95% CI 0.35-0.65), P < 0.0001) and for the different TNFi-types (adalimumab 0.45 (0.27-0.76)/etanercept 0.24 (0.10-0.61)/infliximab 0.57 (0.34-0.95)).

CONCLUSION

In this study of TNFi-treated AS patients in clinical practice, current and previous smokers had significantly poorer patient-reported outcomes at baseline, shorter treatment adherence and poorer treatment response compared with never smokers.

Feasibility of a standardized ultrasound examination in patients with rheumatoid arthritis: a quality improvement among rheumatologists cohort

Background

Quality improvement is important to facilitate valid patient outcomes. Standardized examination procedures may improve the validity of US.

The aim of this study was to investigate the learning progress for rheumatologists during training of US examination of the hand in patients with rheumatoid arthritis (RA).

Methods

Rheumatologists with varying degrees of experience in US were instructed by skilled tutors. The program consisted of two days with hands-on training followed by personal US examinations performed in their individual clinics. Examinations were sent to the tutors for quality control. The US examinations were evaluated according to a scoring sheet containing 144 items. An acceptable examination was defined as > 80% correct scores.

Results

Thirteen rheumatologists participated in the study. They included a total of 104 patients with RA. Only few of the initial examinations were scored below 80%, and as experience increased, the scores improved (p = 0.0004). A few participants displayed decreasing scores.

The mean time spent performing the standardized examination procedure decreased from 34 min to less than 10 minutes (p = 0.0001).

Conclusion

With systematic hands-on training, a rheumatologist can achieve a high level of proficiency in the conduction of US examinations of the joints of the hand in patients with RA. With experience, examination time decreases, while the level of correctness is maintained. The results indicate that US may be applied as a valid measurement tool suitable for clinical practice and in both single- and multi-centre trials.