Objectives Development of a new ultrasound (US) synovitis score (SONography in Arthritis and Rheumatism (SONAR)-7) with evaluation of its diagnostic performance in a cohort of patients with psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), in comparison with healthy controls (HC).Methods We included 121 participants: 41 patients with PsA and 39 patients with axSpA, from six Swiss hospitals and 41 HC. All participants underwent a clinical examination of joints (68/66 tender joint count/swollen joint count (SJC)), followed by a detailed musculoskeletal US examination of 22 joints to assess for greyscale (GS) and power Doppler (PD) synovitis in adherence with the definitions established by the Outcome Measures in Rheumatology US working group.Results The ‘SONAR-7’ score incorporated GS and PD lesions across 14 joints, including four metacarpophalangeal joints, four distal interphalangeal joints of the hands, two metatarsophalangeal joints, knees and wrists. It demonstrated an area under the receiver operating characteristic curve of 0.831 (95% CI 0.76 to 0.90), with an excellent specificity (95.1%) and moderate sensitivity (44%), comparable to existing US scores. The inflammatory components of the SONAR-7 correlated significantly with clinical measures of inflammation and disease activity (correlation: 0.37 for SJC-28, 0.33 for Disease Activity in Psoriatic Arthritis and 0.48 for US enthesitis). New bone formation in the same joints was associated with the Health Assessment Questionnaire (p=0.035) and Bath Ankylosing Spondylitis Metrology Index (p=0.016).Conclusion The SONAR-7 score represents a fast and effective US-based tool for the evaluation of inflammatory and structural joint involvement in patients with PsA and axSpA, with high specificity and meaningful associations with clinical and quality-of-life outcomes.

OBJECTIVES:To determine which anatomical sites and which ultrasonographic entheseal lesions are best able to discriminate between spondyloarthritis (SpA) patients and healthy controls (HC). METHODS:We included patients with psoriatic arthritis (PsA) and axial SpA (axSpA), from six Swiss hospital outpatient clinics, as well as HC. Participants completed quality of life and physical activity questionnaires and underwent a clinical examination of both joints and entheses, followed by a detailed musculoskeletal ultrasound examination including nine entheseal sites bilaterally. Entheses were scored according to the Outcome Measures in Rheumatology criteria, with an additional evaluation of bursae and power Doppler (PD) in the 2-5 mm zone. RESULTS:Overall, 121 participants were included, including 41 with PsA (mean age in years (SD), percentage male: 54.5±11.0, 63.4%), 39 with axSpA (45.1±10.0, 51.3%) and 41 HC (43.9±10.9, 56.1%), with a total of 2178 entheses evaluated. The PsA and axSpA groups showed no significant differences regarding inflammatory markers or disease activity scores.In the univariable analysis, all ultrasonographic lesions at the enthesis showed a significant association with SpA vs HC. Only B-mode inflammatory lesions (OR=1.38, p=0.034) and active enthesitis (OR=4.45, p=0.030) retained this association in multivariable analyses. While 4/9 entheses were associated with SpA in univariable analyses, only the distal patellar ligament insertion remained significantly associated with SpA (OR=1.74, p=0.039) in multivariable analyses. CONCLUSION:To distinguish SpA patients from controls, the sonographic scoring system used should account not only for the presence of specific entheseal lesions (structural and inflammatory) but also for the individual site affected.

Objective Conventional radiography (CR) and ultrasound (US) are used interchangeably for identification of calcium pyrophosphate deposition (CPPD). The aim of this study was to assess whether combining US and CR offers greater accuracy over either modality alone for the identification of CPPD. Methods Consecutive patients scheduled for knee replacement surgery for osteoarthritis were enrolled. Before surgery, patients underwent CR and US of the knee. Menisci and hyaline cartilage were collected and analyzed using polarized light microscopy to confirm the presence of CPPD (gold standard). CR and US were assessed for absence/presence of CPPD by expert radiologists and sonographers. Diagnostic performance statistics were calculated. Poisson models with robust variance estimators were used to determine the likelihood of identifying CPPD. Results Fifty-one patients (63% female, mean age 71.4 [SD 8] years) were enrolled. US demonstrated higher overall accuracy than CR for CPPD identification (0.78 vs 0.73). Sequential use of both modalities provided an advantage when only 1 knee site was positive in 1 of the 2 techniques; however, when 2 or 3 sites were positive, no additional advantage was observed. When US was negative, subsequent CR did not improve CPPD detection, but in cases of a negative CR, a positive US increased the likelihood of CPPD by 4.21 times, whereas a negative US substantially reduced the probability of CPPD, increasing the likelihood of its absence by 76%. Conclusion US was more accurate than CR for identification of CPPD. Performing both exams can be an added value for CPPD identification only in a few specific cases.

Objective To formulate evidence-based recommendations and overarching principles on the use of imaging in the clinical management of crystal-induced arthropathies (CiAs). Methods An international task force of 25 rheumatologists, radiologists, methodologists, healthcare professionals and patient research partners from 11 countries was formed according to the EULAR standard operating procedures. Fourteen key questions on the role of imaging in the most common forms of CiA were generated. The CiA assessed included gout, calcium pyrophosphate deposition disease and basic calcium phosphate deposition disease. Imaging modalities included conventional radiography, ultrasound, CT and MRI. Experts applied research evidence obtained from four systematic literature reviews using MEDLINE, EMBASE and CENTRAL. Task force members provided level of agreement (LoA) anonymously by using a Numerical Rating Scale from 0 to 10. Results Five overarching principles and 10 recommendations were developed encompassing the role of imaging in various aspects of patient management: making a diagnosis of CiA, monitoring inflammation and damage, predicting outcome, response to treatment, guided interventions and patient education. Overall, the LoA for the recommendations was high (8.46-9.92). Conclusions These are the first recommendations that encompass the major forms of CiA and guide the use of common imaging modalities in this disease group in clinical practice.

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.

Background The multifaceted clinical presentation in crystal-induced arthropathies (CiA) poses challenges to imaging. Objectives To formulate evidence-based recommendations on the use of imaging in the diagnosis and management of CiA. Methods Following EULAR standard operating procedures a task force of 25 stakeholders from 11 countries was created. Four systematic literature searches were performed in MEDLINE, EMBASE and CENTRAL to guide task force decisions, answering 14 research questions on the role of imaging in gout, calcium pyrophosphate and basic calcium phosphate deposition disease. Level of agreement (LoA) with each overarching principle and recommendation was assessed by numerical rating scale (0-10). Results Five overarching principles and 10 recommendations were produced on the role of imaging in making a diagnosis, monitoring, predicting, guiding intervention, and patient education in CiA (Table 1). Overall, the LoA for the recommendations was very high (8.5-9.9). Conclusion These are the first recommendations that encompass all common forms of CiA and guide the use of established imaging modalities in this disease group. REFERENCES: NIL. Acknowledgements: NIL. Disclosure of Interests Peter Mandl: None declared, Maria-Antonietta D'Agostino: None declared, Victoria Navarro-Compán: None declared, Irina Gessl: None declared, Garifallia Sakellariou: None declared, Abhishek Abhishek: None declared, Fabio Becce Consultant of: Horizon, Grant/research support from: Siemens Healthineers, Nicola Dalbeth: None declared, Hang Korng Ea: None declared, Emilio Filippucci: None declared, Hilde Berner Hammer: None declared, Annamaria Iagnocco: None declared, Annette de Thurah: None declared, Esperanza Naredo: None declared, Sebastien Ottaviani: None declared, Tristan Pascart Consultant of: Novartis, Grant/research support from: Horizon Pharmaceuticals, Fernando Perez-Ruiz: None declared, IRENE Pitsillidou: None declared, Fabian Proft: None declared, Jürgen Rech: None declared, Wolfgang A. Schmidt: None declared, Luca Maria Sconfienza Consultant of: Esaote SPA, Samsung Medison, Fidia Farmaceutici, Pfizer, Novartis, Janssen Cilag, Abiogen, Bracco Imaging Italia, MSD, Merck Serono, Grant/research support from: Esaote SPA, Samsung Medison, Fidia Farmaceutici, Pfizer, Novartis, Janssen Cilag, Abiogen, Bracco Imaging Italia, MSD, Merck Serono, Lene Terslev: None declared, Brigitte Wildner: None declared, Pascal Zufferey: None declared, Georgios Filippou: None declared.Table 1EULAR recommendations for the use of imaging in CiA in clinical practiceOverarching principlesLevel of agreement Mean (standard deviation)A. CiA are typically characterized by intermittent, acute episodes of inflammation, but may also exhibit a persistent disease course with or without superimposed flares.9.8 (0.5)B. Imaging in CiA provides useful information on crystal deposition, inflammation, and structural damage.9.8 (0.5)C. The presence of imaging abnormalities, in particular those related to crystal deposition, may not always be related to clinical manifestations.9.8 (0.5)D. Patient information (medical history, physical/laboratory examination, synovial fluid/tissue analysis) should be taken into account when imaging is considered in CiA.9.7 (0.7)E. Imaging in CiA should be performed and interpreted by trained health care professionals.9.9 (0.4)Recommendations1. When performing imaging in CiA, both symptomatic areas and disease-specific target sites (i.e. MTP1 in gout, wrist and knee in CPPD, shoulder in BCPD) should be considered.9.7 (0.5)2. In the diagnostic assessment of gout, US and DECT are both recommended imaging modalities.9.7 (0.6)3. When characteristic features of MSU crystal deposition on US (i.e. double contour sign or tophi) or on DECT are identified, synovial fluid analysis is not needed to confirm a diagnosis of gout.8.8 (1.8)4. In the diagnostic assessment of CPPD, CR and US (or CT if axial involvement is suspected) are recommended imaging modalities.9.6 (0.9)5. In the diagnostic assessment of BCPD, imaging is necessary; CR or US are the recommended modalities.9.1 (1.7)6. In gout, US and DECT can be used to monitor crystal deposition and in case of US, also inflammation. Both modalities provide additional information on top of clinical and biochemical assessment. In case US/DECT are not available, CR can be used to assess structural damage due to gout. The decision on when to repeat imaging depends on the clinical circumstances.9.3 (1.2)7. In CPPD and BCPD serial imaging is not recommended, unless there is an unexpected change in clinical characteristics.9.4 (1.2)8. In gout, assessing the amount of MSU crystal deposition by US or DECT may be used to predict future flares.8.5 (1.7)9. If synovial fluid analysis is required in the assessment of CiA, US-guidance should be used in cases where aspiration based on anatomical landmarks is challenging.9.7 (0.5)10. Showing and explaining imaging findings of CiA to people with such conditions may help them understand their condition and improve treatment adherence in gout.9.4 (0.9)BCPD: basic calcium phosphate deposition disease; CiA: crystal-induced arthropathies; CPPD: calcium pyrophosphate deposition disease; CR: conventional radiography; CT: computed tomography; DECT: dual-energy computed tomography; MSU: monosodium urate; MTP: metatarsophalangeal joint; US: ultrasound

Background In Switzerland, rituximab (RTX) is licenced for the treatment of rheumatoid arthritis (RA) and ANCA-associated vasculitis (AAV) but is frequently used off-label to treat other auto-immune diseases (AID), especially connective tissue diseases (CTD). We aimed to characterise the use of RTX in AID in a real-life Swiss setting and compare RTX retention rates and safety outcomes between patients treated for RA, CTD and AAV. Methods A retrospective cohort study of patients who started RTX in the Rheumatology Department for RA or AID. The RTX retention rate was analysed using Kaplan–Meier survival curves. Occurrences of serious adverse events (SAE), low IgG levels and anti-drug antibodies (ADA) were reported. Results Two hundred three patients were treated with RTX: 51.7% had RA, 29.6% CTD, 9.9% vasculitis and 8.9% other AIDs. The total observation time was 665 patient-years. RTX retention probability at 2 years (95%CI) was similar for RA and CTD 0.65 (0.55 to 0.73), 0.60 (0.47 to 0.72) and lower for vasculitis 0.25 (0.09 to 0.45). Survival curves for RTX retention matched closely ( p = 0.97) between RA and CTD patients but were lower for patients with vasculitis due to a higher percentage of induced remission. Patients with vasculitis (95%) and CTD (75%) had a higher rate of concomitant glucocorticoid use than RA (60%). Moderate to severe hypogammaglobulinaemia was observed more frequently in patients with vasculitis (35%) than with RA (13%) or CTD (9%) and was associated with an increased risk of presenting a first infectious SAE (HR 2.01, 95% CI 1.04 to 3.91). The incidence rate of SAE was 23.3 SAE/100 patient-years (36% were infectious). When searched, ADAs were observed in 18% of the patients and were detected in 63% of infusions-related SAE. 10 patients died during RTX treatment and up to 12 months after the last RTX infusion, 50% from infection. Conclusion RTX retention rates are similar for patients with RA and CTD but lower for those with vasculitis due to more frequent remission. Patients treated with RTX for vasculitis present more SAE and infectious SAE than patients with RA and CTD, potentially due to a higher use of concomitant glucocorticoids and the occurrence of hypogammaglobulinaemia.

Recently, serious infections related to the use of tofacitinib (TOF) for treatment of rheumatoid arthritis (RA) have raised considerable interest. This study aimed to compare the risk for serious infections in patients with RA upon receiving TOF versus biologic disease-modifying antirheumatic drugs (bDMARDs) by age at treatment initiation. We identified adult RA patients exposed to TOF or bDMARDs using data collected by the Swiss registry for inflammatory rheumatic diseases (SCQM) from 2015 to 2018. The event of interest was the first non-fatal serious infection (SI) during drug exposure. Missing or incomplete SI dates were imputed as either the lower (left) or upper (right) limit of the known occurrence interval. The ratio of SI hazards (HR) of TOF versus bDMARDs was estimated as a function of age using covariate-adjusted Cox regression applied to each type of imputed time-to-SI. A total of 1687 patients provided time at risk for a first SI during study participation and drug exposure for 2238 different treatment courses, 345 for TOF and 1893 for bDMARDs. We identified 44 (left imputation) or 43 (right imputation), respectively, first SIs (12/12 on TOF versus 32/31 on bDMARDs). Left and right imputation produced similar results. For patients aged ≥ 69 years, the treatment HR started to be increased (lower limit of 95% confidence intervals (LLCIs) > 1). By the age of 76, the difference between TOF and bDMARDs started to be clinically relevant (LLCIs > 1.25). For patients aged < 65 years, the data were insufficient to draw conclusions. Our results suggest that we should expect an increased risk for SIs in older patients treated with TOF compared to bDMARDs supporting a cautious use of TOF in these patients.

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.

Colombia. Methods: Sixty-seven patients with chronic arthralgia and 15 patients without arthralgia were followed up a mean of 40 months after chikungunya infection. The patients came from a larger cohort of 500 patients previously followed up 20 months after infection. Those consenting to a 40month in-person follow-up were included here. Tender joint counts, a pain intensity visual analogue scale (VAS), Health Assessment QuestionnaireDisability Index (HAQ-DI) and the EuroQol overall health VAS (EQ-VAS) were completed. A 21-item musculoskeletal stiffness questionnaire (MSQ) was completed and summarized as percentage scores for overall stiffness and its components: stiffness severity, physical impact and psychosocial impact. Results: The 82 patients (12 male and 70 female) had a mean age 51 ±14 years. Forty-two out of sixty-seven patients with arthralgia and 3/15 patients without arthralgia reported musculoskeletal stiffness. Stiffness in those patients had a median severity of 28% (IQR 0-42). An impact of their stiffness on physical activities was reported by 39/45 patients (87%) and psychosocial impact by 32/45 patients (71%). Overall MSQ score was a median of 16% (IQR 0-34). Mean tender joint count in patients reporting arthralgia was 6.2±7.1, mean pain intensity 65±20 out of 100, mean HAQ-DI = 0.54±0.52, and a mean EQ-VAS = 68±62 out of 100. Overall stiffness scores were poorly correlated with tender joint counts (r=0.17) and pain intensity (r=0.22). Stiffness scores were more strongly associated with the HAQ-DI (r=0.52) and EQ-VAS overall health VAS scores (r=0.46), whereas tender joint counts were not: r=0.22 for HAQDI and r=0.21 for EQ-VAS. Conclusion: Musculoskeletal stiffness following chikungunya infection is distinct from the persistent arthralgia usually reported. It does not necessarily occur in the same patients and is poorly correlated with joint pain severity. Stiffness, as measured by this questionnaire, may be more strongly associated than arthralgia with overall health and disability indices in patients with chikungunya disease. The MSQ is a potentially useful instrument for assessing symptoms in chronic chikungunya disease. Disclosure of Interests: Hugh Watson Shareholder of: Sanofi, Employee of: Sanofi, Sarah Tritsch: None declared, Liliana Encinales: None declared, Andres Cadena: None declared, Carlos Cure: None declared, Alexandra Porras: None declared, Alejandro Rico Mendoza: None declared, Aileen Chang: None declared DOI: 10.1136/annrheumdis-2019-eular.4048

Objective:The role of US-detected tenosynovitis (USTS) in the management of rheumatoid arthritis remains controversial. The aim of this study was to investigate whether tenosynovitis can predict a flare in rheumatoid arthritis patients in remission in a real-life cohort.Methods:Rheumatoid arthritis patients from the Swiss Clinical Quality Management cohort were included in this study if they were in clinical remission, defined by 28-joint disease activity score (DAS28-ESR) <2.6, and had an available B-mode tenosynovitis score. The patients were stratified according to the presence or absence of tenosynovitis (USTS+ vs. USTS-). Cox proportional hazard models were used for time-to-event analysis until the loss of remission, after adjustment for multiple confounders. The impact of baseline US performed early in remission and the advent of flares at different fixed time periods after baseline were investigated in sensitivity analysis.Results:Tenosynovitis was detected in 10% of 402 rheumatoid arthritis patients in remission. At baseline, USTS+ patients in remission had significantly higher DAS28-ESR (mean (SD): USTS- 1.8 (0.5) versus USTS+ 2.0 (0.5); p = 0.0019) and higher additional disease activity parameters, such as physician global assessment, and simplified- and clinical-disease activity index. Joint synovitis detected by B-mode US was associated with tenosynovitis (mean (SD) 7.2 (6.3) in USTS- versus 9.0 (5.4) in USTS+, respectively; p = 0.02). A disease flare was observed in 69% of remission phases, with no differences in the time to loss of remission between USTS+ and USTS- groups.Conclusion:While US-detected tenosynovitis was associated with higher disease activity parameters in rheumatoid arthritis patients in clinical remission, it was not able to predict a flare.

BackgroundMusculoskeletal ultrasound (US) has been reported to predict radiographic progression in rheumatoid arthritis (RA).ObjectivesTo test the predictive value of composite disease activity indices (DAI) based on solely clinical as well as clinical and US (USDAI) information to predict radiographic progression in RA.MethodsData from the Swiss Clinical Quality Management (SCQM) database were extracted from patients with RA; USDAIs were created based on previous publications (1) (Table 1). In summary, the disease activity score in 28 joints (DAS28) and the simplified disease activity index (SDAI) were modified by supplementing or replacing the clinical swollen JC with joints showing signs of power Doppler (PD) and/or grey scale (GS) synovitis. Series with two standard x-rays of the hands (difference ≥ 183 days) and ≥1 visit with clinical and US data in between were analyzed. Progression was defined as an increase of ≥6.27 points of the Ratingen-Rau x-ray score. Receiver operating curve (ROC) analyses were used to assess predictive ability of every DAI for radiographic progression. As a subanalysis, ROCs using the median DAIs of series with ≥2 DAIs between two x-rays were run. Clinical DAS28/SDAIs were compared to their respective USDAI counterpart with the highest area under the curves (AUC).Table 1.Area under the curves (AUC) of receiver operating characteristic curves for the predictive value of the composite disease activity indices for radiographic progression. DAI disease activity index; DAS28, disease activity score for 28 joints; GS, grey scale; PD, power Doppler; SDAI, simplified disease activity index; SJC: swollen joint count; + positiveDisease activity indexesAll seriesSeries with ≥ 2 DAIs95% CI95% CIAUCLowerUpperAUCLowerUpperDAS28.58.52.58.62.45.78DAS28_GSSJC replaced by GS+ joints.56.49.56.62.44.80DAS28_PDSJC replaced by PD+ joints.60.53.60.63.46.81DAS28_GSPDSJC replaced by GS AND PD+ joints.57.50.57.62.44.80DAS28_plus_GSSJC supplemented by GS+ joints.57.50.57.62.44.8ßDAS28_plus_PDSJC supplemented by PD+ joints.59.52.59.61.43.79DAS28_plus_GSPDSJC supplemented by GS AND PD+ joints.57.50.57.62.44.79SDAI.57.50.57.48.26.70SDAI_GSSJC replaced by GS+ joints.53.46.53.47.23.71SDAI_PDSJC replaced by PD+ joints.58.52.58.51.27.75SDAI_GSPDSJC replaced by GS AND PD+ joints.53.46.53.47.23.71SDAI_plus_GSSJC supplemented by GS+ joints.54.47.54.47.23.70SDAI_plus_PDSJC supplemented by PD+ joints.58.51.58.48.25.72SDAI_plus_GSPDSJC supplemented by GS AND PD+ joints.54.47.54.46.23.70ResultsWe included 649 series in 475 patients. Progression was observed in 84/649 (12.9%) series. Mean difference between the x-rays was 27.6±18.0 months. Mean age was 56.3±12.7 years, 474/649 (73%) series were from female patients. There was no significant difference between the AUC of the ROC of SDAI vs. SDAI_PD (p=0.19) nor between DAS28 vs. DAS28_PD: (p=0.17) (Figure 1A, Table 1). Similarly, when analyzing only series with ≥2 DAIs (143 series) we observed no difference between the AUC of the ROC of SDAI vs. SDAI-PD (p=0.28) nor between that of DAS28 vs. DAS28_PD (p=0.23) (Figure 1B, Table 1).Figure 1.Receiver operating characteristic (ROC) curve of clinical and ultrasound-based composite disease activity indices (A) overall and (B) for the subgroup with series with ≥ disease activity indices. DAS, disease activity score; GS, grey scale; PD, power Doppler; SDAI, simplified disease activity index;ConclusionThe predictability of radiographic progression by disease activity measures was generally limited. The composite USDAIs containing sonographic JC were not superior for predicting radiographic progression compared to their clinical counterparts although there was a trend for higher predictive value for indices containing PD.References[1]Mandl P, Balint P, Brault Y et al. Arthritis Care Res 2013;65:879-87.Disclosure of InterestsIrina Gessl: None declared, Thomas Deimel: None declared, Paul Studenic: None declared, Giorgio Tamborrini: None declared, Pascal Zufferey: None declared, Daniel Aletaha Speakers bureau: Abbvie, Amgen, Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Grant/research support from: Abbvie, Amgen, Lilly, Novartis, Roche, SoBi, Sanofi, Burkhard Moeller: None declared, Peter Mandl Speakers bureau: from AbbVie, Janssen and Novartis, Grant/research support from: from AbbVie, BMS, Novartis, Janssen, MSD and UCB

Objective To evaluate the discriminatory ability of ultrasound in calcium pyrophosphate deposition disease ( CPPD), using microscopic analysis of menisci and knee hyaline cartilage (HC) as reference standard. Methods Consecutive patients scheduled for knee replacement surgery, due to osteoarthritis (OA), were enrolled. Each patient underwent ultrasound examination of the menisci and HC of the knee, scoring each site for presence/absence of CPPD. Ultrasound signs of inflammation (effusion, synovial proliferation and power Doppler) were assessed semiquantitatively (0-3). The menisci and condyles, retrieved during surgery, were examined microscopically by optical light microscopy and by compensated polarised microscopy. CPPs were scored as present/absent in six different samples from the surface and from the internal part of menisci and cartilage. Ultrasound and microscopic analysis were performed by different operators, blinded to each other's findings. Results 11 researchers from seven countries participated in the study. Of 101 enrolled patients, 68 were included in the analysis. In 38 patients, the surgical specimens were insufficient. The overall diagnostic accuracy of ultrasound for CPPD was of 75%-sensitivity of 91% (range 71%-87% in single sites) and specificity of 59% (range 68%-92%). The best sensitivity and specificity were obtained by assessing in combination by ultrasound the medial meniscus and the medial condyle HC (88% and 76%, respectively). No differences were found between patients with and without CPPD regarding ultrasound signs of inflammation. Conclusion Ultrasound demonstrated to be an accurate tool for discriminating CPPD. No differences were found between patents with OA alone and CPPD plus OA regarding inflammation.

Background: Acute and chronic shoulder symptoms can be due to calcifications but also to other lesions well detected by Ultrasound (US). Objective: The present study’s objectives were to determine whether, some demographic, clinical and ultrasound features were associated with the presence or absence of calcifications in symptomatic shoulders patients. Methods: As part of this retrospective, transversal, case-control study of 490 patients, the 125 patients with calcifications were compared to 125 patients without calcification randomly extracted from the cohort. Subgroups were defined according to types and durations of symptoms. The frequency and types of associated lesions in the two groups, as well as the different US appearances of the calcifications were compared according to their different clinical presentations. Results: Calcific tendinitis was present in 26% of patients. Demographic characteristics or clinical manifestations, significantly associated with calcifications were: being a woman (p = 0.002), a shorter delay between symptoms and diagnosis (p = 0.007 and have acute symptoms. The presence of calcifications was associated with the absence of associated (42% vs. 6%, p = 0.0001) or less severe associated US lesions, particularly total rotator cuff rupture (5% vs. 18%, p = 0.001). Soft and cystic J Orthop Sports Med 2020; 2 (4): 168182 DOI: 10.26502/josm.511500032 Journal of Orthopaedics and Sports Medicine 169 calcifications without shadowing were found more frequently in patients with hyperalgesic shoulders (p = 0.005) compared to chronic shoulders. Conclusions: Only few demographic and clinical features were significantly more frequent in the presence of calcifications. US revealed fewer additional lesions when calcifications were present and, some US aspects of the calcification suggested the type of symptoms.

Les résultats mesures d’activité de la maladie telles que le score d’activité clinique (DAS 28) ou les scores échographiques sont souvent divergents. Les objectifs de cette étude étaient de déterminer la proportion de désaccords entre ces deux méthodes d’évaluation chez des patients atteints de polyarthrite rhumatoïde (PR) et de décrire les facteurs associés à ces divergences. Tous les patients atteints de PR inscrits dans le registre suisse des arthrites inflammatoires (SCQM) pour lesquels au moins un score DAS 28 et un score échographique concomitant étaient disponibles ont été inclus. L’activité de la maladie a été classée dans plusieurs catégories (rémission, faible à modérée et forte) selon des seuils établis pour les deux scores étudiés. Une analyse longitudinale a été réalisée pour les patients ayant bénéficié d’au moins deux évaluations. Sur les 2369 évaluations incluses (1091 patients), 1196 (50,4 %) étaient divergentes. Par rapport au score DAS 28, le score échographique surestimait et sous-estimait l’activité de la maladie (23,5 % et 26,8 %, respectivement). Les facteurs cliniques et démographiques significativement associés aux résultats divergents étaient les composantes individuelles du score DAS 28 lorsque l’échographie était utilisée comme référence et l’âge, la durée de la maladie et le nombre d’articulations gonflées lorsque la référence était le score DAS 28. Le principal facteur lié à l’échographie ayant été associé à une divergence était la présence d’une ténosynovite échographique. Dans l’analyse longitudinale de 1081 patients, la proportion de désaccords est restée essentiellement la même. Les taux de désaccord entre les évaluations cliniques et échographiques de l’activité de la maladie dans la PR étaient élevés et le sont restés au cours du suivi, même lorsque les évaluateurs échographiques avaient connaissance des résultats de l’examen clinique. Des facteurs liés à l’examen clinique et à l’échographie ont été associés aux divergences.

OBJECTIVE:To compare effectiveness of treatment with secukinumab (SEC) with that of alternative tumour necrosis factor inhibitors (TNFis) in patients with axial spondyloarthritis (axSpA) after withdrawal from one or more TNFis. METHODS:Patients diagnosed as having axSpA in the Swiss Clinical Quality Management cohort were included if they had initiated SEC (n=106) or an alternative TNFi (n=284) after experiencing TNFi failure. Drug retention was investigated with matching weights propensity score (PS) analyses and multiple adjusted Cox proportional hazards models. Matching weights PS-based analyses and multiple-adjusted logistic regression analyses were used to assess the proportion of patients reaching 50% reduction in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI50) at 1 year. RESULTS:SEC was more often used as third-line or later-line biological drug (76% vs 40% for TNFi). Patients starting SEC had higher BASDAI, Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Metrology Index and C reactive protein levels. A comparable risk of drug discontinuation was found for SEC versus TNFi (HR 1.14, 95% CI 0.78 to 1.68 in the PS-based analysis and HR 1.16, 95% CI 0.79 to 1.71 in the multiple-adjusted analysis). No significant difference in BASDAI50 responses at 1 year was demonstrated between the two modes of biological drug action, with CI of estimates being, however, wide (OR for SEC vs TNFi 0.76, 95% CI 0.26 to 2.18 and 0.78, 95% CI 0.24 to 2.48 in the PS-based and the covariate-adjusted model, respectively). CONCLUSION:Our data suggest a comparable effectiveness of SEC versus an alternative TNFi after prior TNFi exposure.

Objectives To evaluate grey scale US (GSUS) and power Doppler US synovitis (PDUS), separately or in combination (CombUS), to predict joint damage progression in RA. Methods In this cohort study nested in the Swiss RA register, all patients with sequential hand radiographs at their first US assessment were included. We analysed the summations of semi-quantitative GSUS, PDUS and CombUS assessments of both wrists and 16 finger joints (maximum 54 points) at their upper limit of normal, their 50th, 75th or 87.5th percentiles for the progression of joint damage (ΔXray). We adjusted for clinical disease activity measures at baseline, the use of biological DMARDs and other confounders. Results After a median of 35 months, 69 of 250 patients with CombUS (28%), 73 of 259 patients with PDUS (28%) and 75 of 287 patients with available GSUS data (26%) demonstrated joint damage progression. PDUS beyond upper limit of normal (1/54), GSUS and CombUS each at their 50th (9/54 and 10/54) and their 75th percentiles (14/54 and 15/54) were significantly associated with ΔXray in crude and adjusted models. In subgroup analyses, GSUS beyond 14/54 and CombUS higher than 15/54 remained significantly associated with ΔXray in patients on biological DMARDs, while clinical disease activity measures had no significant prognostic power in this subgroup. Conclusion Higher levels of GSUS and CombUS are associated with the development of erosions. GSUS appears to be an essential component of synovitis assessment and an independent predictor of joint damage progression in patients on biological DMARDs.