ObjectivesThis study aimed to determine the prevalence of ultrasound-detected tendon abnormalities in healthy subjects (HS) across the age range.MethodsAdult HS (age 18–80 years) were recruited in 23 international Outcome Measures in Rheumatology ultrasound centres and were clinically assessed to exclude inflammatory diseases or overt osteoarthritis before undergoing a bilateral ultrasound examination of digit flexors (DFs) 1–5 and extensor carpi ulnaris (ECU) tendons to detect the presence of tenosynovial hypertrophy (TSH), tenosynovial power Doppler (TPD) and tenosynovial effusion (TEF), usually considered ultrasound signs of inflammatory diseases. A comparison cohort of patients with rheumatoid arthritis (RA) was taken from the Birmingham Early Arthritis early arthritis inception cohort.Results939 HS and 144 patients with RA were included. The majority of HS (85%) had grade 0 for TSH, TPD and TEF in all DF and ECU tendons examined. There was a statistically significant difference in the proportion of TSH and TPD involvement between HS and subjects with RA (HS vs RA p<0.001). In HS, there was no difference in the presence of ultrasound abnormalities between age groups.ConclusionsUltrasound-detected TSH and TPD abnormalities are rare in HS and can be regarded as markers of active inflammatory disease, especially in newly presenting RA.

BackgroundMusculoskeletal ultrasound improves the accuracy of detecting the level of disease activity (DA) in RA patients, although its impact on the final treatment decision in a real clinical setting is uncertain. The objectives were to define the percentage of clinical scenarios from an ongoing cohort of RA outpatients in which the German Ultrasound Score on 7 joints (GUS-7) impacted the treatment and to explore if the impact differed between a senior rheumatologist (SR) vs. a trainee (TR).MethodsEighty-five consecutive and randomly selected RA outpatients underwent 170 assessments, 85 each by the SR and the TR. Initially, both physicians (blinded to each other) performed a rheumatic assessment and recommended a preliminary treatment. Then, the patients underwent the GUS-7 evaluation by an experienced rheumatologist blinded to clinical evaluations; selected joints of the clinically dominant hand were assessed by gray-scale and power Doppler (PD). In the final step, the TR and the SR integrated the GUS-7 findings with their previous evaluation and reviewed their recommendations. The patients received the final recommendation from the SR to avoid patient confusion. The study was approved by the Internal Review Board and all the patients signed informed consent. GUS-7 usefulness was separately evaluated by the SR and the TR according to a visual analogue scale (0 = not useful at all, 10 = very useful). Descriptive statistics were used.ResultsThe patients were primarily middle-aged females (91.4%) with (mean ± SD) disease duration of 7.5 ± 3.9 years. The majority of them (69.2% according to TR and 71.8% to SR) were in DAS28-ESR-remission. In 34 of 170 clinical scenarios (20%), the GUS-7 findings modified the final treatment proposal; 24 of these scenarios were determined by the TR vs. 10 by the SR: 70.5% vs. 29.5%, p = 0.01. Treatment changes (increase, decrease and joint injection) were similar between both specialists. As expected, the TR rated the GUS-7 usefulness higher than the SR, particularly in the clinical scenarios where the GUS-7 findings impacted treatment.ConclusionsMusculoskeletal ultrasound added to standard rheumatic assessments impacted the treatment proposal in a limited number of patients; the impact was greater in the TR.

Background:Tenosynovitis (TS) is a common, often clinically undetectable finding in Rheumatoid Arthritis (RA). Recent data showed TS on ultrasound (US) has a role in predicting outcome in early disease and flare in clinical remission. However data is limited on US measured TS in healthy subjects (HS), none specifically encompassing the older age range when RA commonly presents.Objectives:This OMERACT study aimed to determine prevalence of US measured tendon abnormalities in HS throughout the age range.Methods:Adult HS without: joint pain (VAS <10/100), hand osteoarthritis (ACR criteria), or inflammatory arthritis were recruited in 23 international centres from Aug 2017-Dec 2018. MCP, PIP and wrist joints were clinically examined. Bilateral digit flexor (DF) 1-5 and extensor carpi ulnaris (ECU) tendons were scanned for tenosynovial hypertrophy (TSH) and power Doppler (PD) signal and graded (OMERACT US scoring system1).A comparison cohort of DMARD-naive patients with RA (ACR-EULAR 2010 and/or 1987 criteria) at presentation was taken from the Birmingham Early Arthritis (BEACON) inception cohort, who underwent identical tendon US assessment. They were grouped into ≤12 and > 12 weeks from symptom onset.Results:Data from 899 HS and 144 RA patients were included. HS 18-39 y HS 40-59 y HS ≥60 y RA ≤12 RA > 12 5 groups p value RA ≤12 vs >12 p value n 40831118030114 Age, y (IQR) 29 (25-33)49 (44-55)68 (62-72)58 (52-69)53 (42-65)<0.0010.03 Female (%) 270 (66)270 (83)114 (62)20 (67)86 (75)<0.0010.2 DAS 28 CRP (IQR) ---5.4 (4.2-6.1)4.8 (4.1-5.7)-0.1 Tender joint* (IQR) 0 0 0 18 (10-23)17 (11-29)<0.0010.9 Swollen joint* (IQR) 0 0 0 8 (3-18)6 (3-9)<0.0010.1 DF 1-5 TSH gd ≥1 (%) 8 (0.2)9 (0.3)2 (0.1)54 (18)125 (11)<0.0010.06 DF 1-5 PD gd ≥1 (%) 3 (0.05)2 (0.06)0 49 (16)85 (8)<0.0010.02 ECU TSH gd ≥1 (%) 1 (0.1)11 (1.8)5 (1.4)13 (22)52 (23)<0.0010.8 ECU PD gd ≥1 (%) 0 0 0 12 (20)50 (22)<0.0010.7*RA had 66/68 joint countPrevalence of TSH and particularly PD abnormalities in HS was very low at all ages, and was all grade 1 except in one individual ECU tendon. ECU TSH grade≥1 was more common than DF grade≥1 in the older HS groups, and less common in the 18-39 age group (p=0.011). TSH and PD of grade ≥1 were common in RA patients, with DF PD abnormalities more common in early disease (p=0.02).Conclusion:Low prevalence of TSH or PD abnormalities in tendons of HS even in old age suggests US determined TS will be a robust tool in clinically managing RA.References:[1] Naredo E, D’Agostino MA, et al. Reliability consensus-based US score TS RA. ARD.2013;72(8):1328-34Disclosure of Interests:Jeanette Trickey: None declared, Ilfita Sahbudin: None declared, Alessandra Bortoluzzi: None declared, Annamaria Iagnocco: None declared, Carlos Pineda: None declared, Cesar Sifuentes-Cantú: None declared, Coziana Ciurtin: None declared, Cristina Reategui Sokolova: None declared, Daniela Fodor: None declared, Ellen-Margrethe Hauge: None declared, Esperanza Naredo Consultant for: Abbvie, Speakers bureau: AbbVie, Roche, Bristol-Myers Squibb, Pfizer...

BackgroundRemission or low disease activity is the therapeutic target of rheumatoid arthritis (RA). There is a consistent body of evidence supporting the value of ultrasound (US) findings in the diagnosis, disease activity and treatment monitoring of RA patients. In spite of these pieces of information, the real impact of US in treatment decisions in patients has not yet sufficiently studied.ObjectivesTo explore the impact of US findings, in terms of proportion of patients in whom treatment recommendation differed after the US examination, in RA outpatients. We also tested the variations of US impact according to the level of patient's disease activity or the physician's experience.MethodsThirty-five consecutive outpatients were included. In the 1st step a senior rheumatologist (SR) and a trainee in rheumatology (TR), blinded to each other evaluations performed a clinical evaluation including DAS28, then, they independently proposed a treatment recommendation. In the 2nd step, all patients underwent an US examination using the 7-joint US score (2) by an experienced rheumatologist blinded to clinical evaluation, in order to established the sonographic disease activity. In the final step, all the patients returned to both, the SR and the TR, who integrated the US findings to their previous evaluation and reviewed their prescription. Potential changes of treatment (pre- and post-US) between both physician's (SR and TR) were recorded on standardized formats. Patients received final recommendation only from the SR. US usefulness was separately evaluated by the SR and the TR according to a Likert scale (0= not useful at all, 10= very useful).ResultsPatients were mainly female (91.4%), with (mean±SD) 44.8±10.1 years of age and (median, Q25-Q75) disease duration of 6.5 years (2.9–11.2). Fifty-one (73%) patients were in DAS28-remission and 29 (27%) showed some disease activity. In 17 clinical evaluations (25%), data from US evaluation modified treatment and it was most frequently increased (64.7%). Interestingly, DAS28 was higher in clinical evaluations where US impacted treatment than in those where US did not: (median [Q25-Q75] DAS28: 2.6 (1.6–3.2) vs. 1.6 (1.1–2.2), p=0.009. Also, there was a higher proportion of active patients among the first group: 47% vs. 20.7%, p=0.06. Twelve of the 17 clinical evaluations where US modified treatment recommendation, were performed by TR vs. 5 performed by the SR: 71% vs. 29%, p=0.09; nonetheless, US usefulness was equally scored by both physicians: 3 (2–7) vs. 3 (2–5), p=0.5.ConclusionsUS was an important technique for the treatment decision in routine clinical practice of patients with RA; the impact of US was more frequent in patients with active disease and in TR.ReferencesJoshua F et al. Summary findings of a systematic review of the ultrasound assessment of synovitis. J Rheumatol 2007;34: 839–47.Backhaus et al. Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project. Arthritis Rheum. 2009;61: 1194–201.Disclosure of InterestNone declared