Background Ultrasound (US) examination is able to show subclinical synovitis and structural changes of joints in patients (pts) with RA in clinical remission (CR). Objectives To investigate the differencies of US examination of small joints of hands, feet and wrists in pts with very early (VERA, <1y) vs early (ERA, <3y duration) vs long lasting RA (LRA, >7 y duration) in clinical remission (CR). Methods In 2015 an educational event (RECALL survey) focused on the added value of US in RA pts was held in 22 rheumatology centers in Italy. In every center, the local rheumatologists provided RA pts to be examined by US. Pts signed an informed consent and a brief history of them was collected by the local rheumatologists (previous and current therapy, DAS28, HAQ score). Bilateral US examinations of wrists, metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints were performed by rheumatologists expert in US, to assess synovitis (joint effusion, synovial proliferation, and power Doppler (PD) signal), and bone erosions, using a Logiq E R7, General Electrics, with a 4.2–13 MHz linear probe. All US findings were scored using a 4 degree semiquantitative scoring system. Results Eighty-eight pts were classified as VERA, 183 as ERA and 165 as LRA. Drug usage was not different among the three groups of pts. LRA patients were older (p<0.001), had longer disease remission before US examination (p<0.001) and had an higher prevalence of female sex (p<0.01). Table 1 reports the differences of US examination between VRA vs ERA vs LRA patients. LRA patients had more erosions at MTP and wrists with no differences at MCP joints. Synovial hypertrophy and PD signal had the same degree and distribution in the two groups of patients. LRA patients had more MTP joints with effusion with lower degree as compared to patients with ERA and VERA (see table 1). Conclusions At US examination VERA, ERA and LRA pts in CR have the same degree of synovial hyperplasia and PD signal despite the differences of duration of CR. Higher degree of erosive disease (at wrist and MTP joints), lower degree of MTP effusion and higher prevalence of joint effusion at MTP joints were present among LRA vs ERA and VERA pts. Disclosure of Interest None declared

Background Ultrasound (US) is able to show subclinical synovitis in patients (pts) with rheumatoid arthritis (RA) who are in clinical remission (CR); this has been proposed as a predictive factor for both clinical flares and progression of the structural damage in CR pts. Objectives To investigate the US characteristics of RA pts presenting either CR or low disease activity (LDA). Methods In 2015 an educational event focused on the added value of US in RA pts was held in 22 rheumatology centers in Italy. After a brief presentation on the evidence of US added value for the clinician given by expert sonographers (rheumatologists with a special interest in US that were performing US as their usual activity for many years), in every center, the local rheumatologists provided RA pts to be examined by US. All the US machines were identical both for type (Logiq E R7, General Electrics, with a 4.2–13 MHz linear probe) and settings (both for grey-scale and power Doppler (PD)). Pts signed an informed consent and a brief history of them was collected by the local rheumatologists (previous and current therapy, DAS28, HAQ score). The US examination was performed bilaterally on wrists, MCP and MTP joints, looking for synovitis (effusion, synovial proliferation and PD signal) and bone erosions. The positive findings were scored according to a 0–3 score for synovitis components and presence/absence for erosions; the number and size of the largest erosion was also registered. Results Demographic and descriptive data of the 433 pts examined are reported in Table I. Pts were divided on the basis of the DAS28 result. Statistically significant differences in age and disease duration were registered between the group in CR and the group with DAS28≥3.2 (p=0,019 and p=0,012, respectively), while no differences were found for HAQ or MTX use. Higher positivity of findings, regardless which was the score, was present in LDA group for effusion, synovial proliferation and PD signal. Significant differences were seen between CR and LDA group for effusion (general, MCP and MTP joints; p=0,011, p=0,026, p=0,017 and p=0,013, respectively), PD positivity (general, wrist, MCP and MTP joints; p=0,006, p=0,023 and p=0,05, respectively) and erosions (p=0,002), with higher positivity for pts in LDA. Conclusions The US assessment in this large cohort of RA pts showed frequent positive findings both in the CR and in the LDA group, confirming the results from previous studies. US is a useful imaging tool for the detection of subclinical joint abnormalities in RA. Disclosure of Interest None declared

Background Ultrasound (US) has shown to be a sensitive imaging tool for the detection of subclinical signs of synovitis in patients (pts) with rheumatoid arthritis (RA); further studies are still required to delineate the impact of US findings in the management of RA pts in daily clinical practice. Objectives To investigate the relationship between US findings indicative of joint inflammation and US bone erosions at joint level in pts with RA. Methods In 2015 an educational event focused on the added value of US in RA pts was held in 22 rheumatology centers in Italy. In every center, the local rheumatologists provided RA pts to be examined by US. Pts signed an informed consent and a brief history of them was collected by the local rheumatologists (previous and current therapy, DAS28, HAQ score). Bilateral US examinations of wrists, metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints were performed by rheumatologists expert in US, to assess synovitis (joint effusion, synovial proliferation, and power Doppler (PD) signal), and bone erosions, using a Logiq E R7, General Electrics, with a 4.2–13 MHz linear probe. All US findings were scored using a 4 degree semiquantitative scoring system. Results In 465 RA pts, a total of 10.230 joints were scanned. Of these joints, 3.969 (39%) showed joint effusion and/or synovial proliferation and 1.784 (17%) were found positive for PD signal. The most frequently involved joints were the wrists followed by the second MCP joints and first MTP joints. In 749 joints US detected at least one bone erosion. The most frequently eroded joints were the wrists, the second and fifth MCP joints and the first and fifth MTP joints. A total of 226 RA pts showed at least one bone erosions and in 181 (80%) of these pts the eroded joints were found positive for PD signal. Conclusions A high prevalence of PD signal was found in the joints found eroded by US. This is the first study providing such an evidence using a portable US equipment. Disclosure of Interest None declared

Background In Rheumatoid Arthritis (RA) treatment response is assessed using standard clinical disease activity measure. However ultrasound (US) is able to show subclinical synovitis in patients (pts) with RA who are in clinical remission (CR); further studies are still required to delineate the impact of US findings in the management of RA pts in daily clinical practice. Objectives to investigate the influence of US on the clinicians9 treatment choices in pts with RA. Methods in 2015 an educational event (RECALL Survey) focused on the added value of US in RA pts was held in 22 rheumatology centers in Italy.In every center, the local rheumatologists provided RA pts to be examined by US. Pts signed an informed consent and a brief history of them was collected by the local rheumatologists (previous and current therapy, DAS28, HAQ score). Bilateral US examinations of wrists, metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints were performed by rheumatologists expert in US, to assess synovitis (joint effusion, synovial proliferation, and power Doppler (PD) signal), and bone erosions, using a Logiq E R7, General Electrics, with a 4.2–13 MHz linear probe. All US findings were scored using a 4 degree semiquantitative scoring system. Results 465 pts were evaluated. Clinicians, after US evaluations, changed therapy in 23.7% of pts, did not change therapy in 35.5% of pts.In general changes of therapy tended to be made by clinicians when joint effusion or power Doppler signal were present (table 1–2). The presence of erosion did not influence the clinicians9 decisions. Conclusions Ultrasound may be an useful tool in daily rheumatologic practice to help clinicians make decisions about how to treat patients with RA. US results, especially joint effusion and Power Doppler signal, may influence the choice of clinicians to modify a patient9s treatment regime. Disclosure of Interest None declared

Objectives The aim of the current study is to collect scientific data on all branded hyaluronic acid (HA) products in Italy that are in use for intra-articular (IA) injection in osteoarthritis (OA) compared with that reported in the leaflet. Methods An extensive literature research was performed for all articles reporting data on the IA use of HA in OA. Selected studies were taken into consideration only if they are related to products based on H As that are currently marketed in Italy with the specific joint indication for IA use in patients affected by OA. Results Sixty-two HA products are marketed in Italy: 30 products are indicated for the knee but only 8 were proved with some efficacy; 9 products were effective for the hip but only 6 had hip indication; 7 products proved to be effective for the shoulder but only 3 had the indication; 5 products proved effective for the ankle but only one had the indication; 6 products were effective for the temporomandibular joint but only 2 had the indication; only 2 proved effective for vertebral facet joints but only 1 had the indication; and 5 products proved effective for the carpometacarpal joint but only 2 had the indication. Conclusions There are only a few products with some evidences, while the majority of products remain without proof Clinicians and regulators should request postmarketing studies from pharmaceuticals to corroborate with that reported in the leaflet and to gather more data, allowing the clinicians to choose the adequate product for the patient.

Objectives This study aimed to assess the responsiveness of ultrasonography (US)-7 in patients with psoriasic arthritis (RA) non responders at only MTX terapy recruided with baseline ecographic positivity per disease activity. Sixty-two RA patients were recruited and followed up for 24 weeks. Methods The clinical, laboratory, and X-ray assessments, along with grayscale US (GSUS) and power Doppler US (PDUS) examinations were performed at baseline, 6, 14, and 24 weeks after adalimumab treatment GSUS for synovitis and PDUS for synovitis and paratendinitis/tenosynovitis were assessed by a semi-quantitative (0 to 3) score, while GSUS for paratendinitis/tenosynovitis and bone erosion was qualitatively assessed as absent or present (0 or 1). US scores in both 7-joint (US7) and 12-joint (US12) systems were evaluated. Results After 6, 14, and 24weeks of treatment with adalimumab, indices such as US scores in both 7-joint (US7) and 12-joint (US12) systems were evaluated. After 6, 14, and 24 weeks of treatment with adalimumab indices such as US scores, 28-joint disease activity (DAS28) score, and tender and swelling joint count were all significantly improved compared to baseline. US7 scores were significantly correlated with that of US12. Strong correlations were identified between most US7 scores with DAS28, health assessment questionnaire (HAQ), and C-reactive protein (CRP) levels. When DAS28 was used as a reference, the US7 cutoff for disease remission was less than 35 for GS+PD and also less than 29 for GS and 1 for PD, respectively Conclusions Additionally, the positive percent agreement, negative percent agreement, and overall percent agreement for GS+PD were 77.78, 76.19, and 76.67%, respectively, which were all higher than that of GS or PD. US7 may be a feasible tool to assess the therapeutic response in RA patients. References Power Doppler ultrasonographic monitoring of response to anti-tumor necrosis factor therapy in patients with rheumatoid arthritis. Naredo E, Moller I, Cruz A, Carmona L, Garido J. Arthritis Rheum. 2008 Aug;58(8):2248–56. doi: 10.1002/art.23682 Skeletal Radiol. 2010 May;39(5):457–65. doi: 10.1007/s00256-009-0824-5. Epub 2009 Nov 20. Semi-quantitative analysis of rheumatoid finger joint synovitis using power Doppler ultrasonography: when to perform follow-up study after treatment consisting mainly of antitumor necrosis factor alpha agent. Kamishima T, Sagawa A, Tanimura K, Shimizu M, Matsuhashi M, Shinohara M, Hagiwara H, Henmi M, Narita A, Terae S, Shirato H. Skeletal Radiol. 2010 May;39(5):457–65. doi: 10.1007/s00256-009-0824-5. Epub 2009 Nov 20. Rheumatoid hand joint synovitis: gray-scale and power Doppler US quantifications following anti-tumor necrosis factor-alpha treatment: pilot study.Ribbens C, André B, Marcelis S, Kaye O, Mathy L, Bonnet V, Beckers C, Malaise MG.Radiology. 2003 Nov;229(2):562–9. Epub 2003 Sep 11 Disclosure of Interest None declared

Background Football is one of the most popular sports in the world. Many players are suffering from disease of the Achilles tendon and the complex of the patellar tendon during periods of intense training with characteristics painful conditions of the tendons. Football players use their tendons to the limit because of the 9intensity of your workouts and frequent games. They participate in tournaments with echographic signs of underlying disease, and most of them play with a certain degree of pain. Objectives To investigate the changes in the players ultrasound at baseline and after participating in a youth football tournament. Methods 72 players were interviewed. 64 of the respondents underwent ultrasound examination before the game. 45 of the 64 players (70%) were scanned again at follow-up after the match. The interviews were conducted by the same person and all scans were done by the same doctor. The players were chosen randomly among those controlled interview Scanning was performed with a 15 MHz linear transducer. E 9was performed a careful examination grayscale and Doppler of the Achilles tendon and patellar complex. Ultimate goal was to determine the amount and distribution of activities Doppler with a score of 0–4. Results Sixty-two players (86%) had severe damage to tendons 80 over the past three years. 45 (50%) covered the whole patellar and 34 (37%) the Achilles tendon. In 60% of the problems they had started slowly and the mean duration of symptoms was 4 months (0–36). The 986% accepted the pain, 21% took painkillers, especially NSAIDs, to be able to play. At baseline, the Doppler activity was evaluated in most players. After the match, these changes were not significantly changed in most investigated regions. However, a very significant increase was observed in the tendons on the non-dominant side: quadriceps (Willcoxon p<0.001), patellar tendon (p<0.05), and Achilles tendon central portion (p<0.05). Conclusions Doppler activity was found in all the tendons of soccer players examined to indicate a high degree of tension of these tendons. An increase in the fraction of color Doppler was significant only at the non-dominant leg. This can be explained by the fact that players load more frequently on this side. Changes Doppler correspond to the highest number of accidents on this side and a possible prognostic value of Doppler information is to be tested in a prospective study. References Cook JL, Khan KM, Harcourt PR, Kiss ZS, Fehrmann MW, Griffiths L, Wark JD. Patellar Tendon Ultrasonography in Asymptomatic Active Athletes Reveals Hypoechoic Regions: A Study of 320 Tendons. Clin J Sport Med. 1998 Apr;8(2):73–7. Ohberg L, Alfredson H, and Khan K. Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment. Br J Sports Med. 2002 Jun;36(3):173–177. Disclosure of Interest None declared

Background Interstitial involvement is a common manifestation in patient with connective tissue disorders, Objectives The aim of our study is to investigate the utility of modified TTUS scoring system compared con HRCT findings of in patients with connective tissue disease with pulmonary involvement in treatment with cyclophosphamide Methods 21 patients with a diagnosis of connective lung involvement in treatment with cyclophosphamide were examined with high resolution transthoracic ultrasonography for detecting of ultrasonography comet tail signe as a ultrasonographyc marker of lung involvement in interstitial in connective disease at time 0 and after 6 and 12 months after initiation of treatment with cyclophosphamide and the results of them were compared with high resolution computed tomography as gold standard method for diagnosis of lung involvemeant in this patients Results In comparation with HRCT as gold standard method, the sensitivity, specificity, positive and negative predictive value of TTUS was 75%, 89%, 95% and 52% respectively. Conclusions Modified TTUS can be useful imaging modality in the evalutation of even early stages of pulmonary involvement in connective lung disaease References Diagnostic Perfomance of lung ultrasound in the diagnosis of pneumonia: a bivariate meta-analysis Qian-Jing Hu*, Yong-Chun Shen*, Liu-Qun Jia, Shu-Jin Guo, Hong-Yu Long, Cai-Shuang Pang, Ting Yang, Fu-Qiang Wen Int J Clin Exp Med 2014;7(1):115-121 Guidelines for the diagnosis and treatment of pulmonary hypertension Nazzareno Galiè (Chairperson) (Italy)*; Marius M. Hoeper (Germany); Marc Humbert (France); Adam Torbicki (Poland); Jean-Luc Vachiery (France); Joan Albert Barbera (Spain); Maurice Beghetti (Switzerland); Paul Corris (UK); Sean Gaine (Ireland); J. Simon Gibbs (UK); Miguel Angel Gomez-Sanchez (Spain); Guillaume Jondeau (France); Walter Klepetko (Austria)Christian Opitz (Germany); Andrew Peacock (UK); Lewis Rubin (USA); Michael Zellweger (Switzerland); Gerald Simonneau (France) Disclosure of Interest None declared

Background The concentrated platelets found in Platelet Rich Plasma (PRP) include growth factors among the huge reservoirs of bioactive proteins that are vital to initiate and accelerate tissue repair and regeneration. Objectives To evaluate the assess the duration of effectiveness of 4 intra-articular injection: two infiltration of platelet gel followed by two ultrasound guided infiltration of hyaluronic acid under ultrasound (US) guidance in symptomatic osteoarthritis of the hip. Methods We treated 46 patients (aged between 45 and 65 years) with symptomatic hip osteoarthritis (radiological grade II/III, Kellgren-Lawrence scale), excluding cases with concomitant rheumatic diseases. 15 Patients were treated with a cycle of 4 intra-articular injections (one every three weeks) under ultrasound guidance of platelet gel obtained by peripheral blood of the patient and performed at basal evaluation and at 1-3-6 months.15 Patients were treated with a cycle of 4 intra-articular injections under ultrasound guidance of ialuronan (Highly Cross-Linked HA – molecular weight approximately 6 million D.) 16 Patients were treated with a cycle of 4 intra-articular injections under ultrasound guidance, but, two infiltration of platelet gel followed by two ultrasound guided infiltration of hyaluronic acid (Highly Cross-Linked HA – molecular weight approximately 6 million D.) under ultrasound (US) guidance. Primary efficacy endpoint was the change of the profile articular cartilage, any fibrillation, erosions and reduction thickness of the center point of the joint space coxofemoral a 6 and 12 months through the 9 ultrasound examination. Primary safety endpoint was the nature, incidence and severity of local and systemic events, acute inflammatory reactions and laboratory evaluations. Secondary endpoints included changes in the thickness of the cartilage coxo femoral total and the width of the joint space measured by X-ray examination, and VAS pain. Results A significant improvement in all the evaluated parameters has been observed from baseline to one year after the end of therapy (p<0.0005); a reduction in VAS score of 50% was observed in 62.5% (n=29), 87.5% (n=40) and 93.7% of patients (n=43) after the 1st, 2nd and 3rd injection, respectively. At the end of the therapy 62.5% of patients (n=29) had a further reduction of VAS score of 70%. Patients observed after one year treated with sequential therapy have maintained a greater reduction in VAS score than patients treated with ialuronan or platelet gel alone and the average reduction in NSAID consumption correlated with the evolution of the VAS score. was associated with a statistically significant and dose-dependent improvement in the total thickness of the hip joint and cartilage volume, and joint space narrowing Conclusions The ultrasound-guided intra-articular treatment with platelet gel and after ialuronan in patients with symptomatic hip osteoarthritis demonstrates in almost all the treated patients (93.7% of cases) a significant reduction of subjective pain (on a VAS scores) and consumption of NSAIDs greater than the ialuronan or platelet gel alone These are preliminary data that need further confirmation in a larger number of patients. References Zimmermann R. et al. Transfusion 2001; 41: 1217-1224. Vogel J. et al. Arch. Orthop. Trauma Surg. 1997; 116: 480-3. Slater M. et al. J. Orthop. Res. 1995; 13: 655-63. Disclosure of Interest None declared

Background The treatment of trapeziometacarpal joint osteoarthritis (TMO) often consists of intra-articular injections of corticosteroids and/or hyaluronic acid (HA) or oral intake of chondroprotector agents. Several studies have shown that ultrasound-guided injections have greater accuracy and effectiveness compared to the blind technique. Objectives The purpose of our retrospective study was to observe if the concomitant administration of two treatments, ultrasound-guided infiltration of HA and the co-administration of chondroitin sulfate (CS) 800 mg daily orally gives superior results compared to the single treatment of infiltrative HA. Methods The patients, aged between 49 and 70 years, were divided into two groups: 12 men and 40 women received only the intra-articular infiltration treatment with 1 ml of HA 0.8% (Sinovial® Mini, one infiltration/month for 6 months) and 8 men and 21 women received the infiltrative treatment combined with oral administration of CS (Condrosulf®) 800 mg/day for 90 days. Hyaluronic acid has been administered by using an ultrasound transducer coupled with a 23G spinal needle, tangentially positioned to the skin (between 15° and 20°), following the course of the needle and the placement of the substance in real time. The patients were evaluated before treatment and at one, three and six months after the first infiltration by using a Visual Analogue Scale (VAS). One month after the end of treatment the patients’ subjective response to therapy was assessed in a 6-point Likert scale, as secondary endpoint. A daily questionnaire was also provided to record the compliance and possible side effects occurring during the treatment. Results A statistically significant reduction in the VAS score from 70 to 30 was observed at 1-3 months (p<0.02) and at the follow up of 6 months (p<0.03) in patients treated only with HA injection, while an even more statistically significant reduction in VAS from 70 to 10 was observed at 3 months (p<0.01) and at the follow up of six months (p<0.02) in patients who received the combined treatment with oral CS and infiltrative HA. None of the patients in the study had problems with respect to the tolerability of both treatments. Conclusions The intra-articular injections of hyaluronic acid has a significant relief from pain by restoring the joint function during the whole follow-up. A more marked reduction of symptoms was observed in patients concomitantly treated with ultrasound-guided infiltration of hyaluronic acid and oral chondroitin sulfate. The new technique of ultrasound-guided infiltration of the trapeziometacarpal joint is easy to implement and shows an excellent precision. References Uebelhart D., Thonar E.J., Delmas P.D. et al. Osteoarthritis Cartilage 1998; 6(Suppl A): 39–46. Morreale P., Manopulo R., Galati M. et al. J. Rheumatol. 1996; 23: 1385–91. Leeb B.F., Petera P., Neumann K. Wien Med Wochenschr 1996; 146: 609–14. Pipitone V., Ambanelli U., Cervini C. et al. Curr. Ther. Res. 1992; 52: 608–38. Grevenstein J., Michiels I., Arens-Corell M., Stofft E. Acta Orthop. Belg. 1991; 57: 157–61. Kerzberg F.M. et al. Scand. J. Rheum. 1987; 16: 377. Moss M. et al. Oral Surg. Oral Med. Oral Path. 1965; 20: 795-801. Disclosure of Interest None Declared