BackgroundAssessment of synovitis in Rheumatoid Arthritis (RA) is a major issue for a proper treatment administration; it has been proven that ultrasound (US) examination could be of valuable help and it is currently being investigated as a possible outcome measure for the disease. It is, though, of greatest importance to accurately establish the place of US scores among the already validated outcome measures, according to Outcome Measures for Rheumatoid Arthritis in Clinical Trials (OMERACT) filter. The present study is designed to compare the results of gray-scale ultrasound (GSUS) and Power Doppler ultrasound (PDUS) additive scores, separately calculated for volar and dorsal aspects of the hand, with physical examination, patient's evaluation of disease pain and global activity on Visual Analogic Scale (VAS) and traditional scores for disease activity assessment (DAS28, CDAI, SDAI, HAQ). The final aim is to prove the advantages of volar US evaluation in RA patients.Methods42 RA patients have been clinically evaluated for pain and swelling of their hand joints, completed VAS and HAQ questionnaires and underwent both volar and dorsal sonography of the hands during the same day. The US examiner was blinded to clinical assessments and lab results. For each patient 20 joints were assessed by sonography (radiocarpal, intercarpal, metacarpophalangeal (MCP) 2-5, proximal interphalangeal (PIP) 2-5). Carpal joints were only evaluated from dorsal view, while MCPs and PIPs were evaluated both from dorsal and volar aspect resulting a total of 36 distinct evaluations for each patient. GSUS synovial hypertrophy was assessed both by quantitative measurement and semiquantitative scale (0-3 grades); Doppler signal (PDUS) was recorded on a semiquantitative scale (0-3 grades). The semiquantitative grades for both GSUS and PDUS evaluation of each joint were added and the sum was defined as the Echographic Score (ES) of each patient. Separately, we added the semiquantitative grades for volar and dorsal side, resulting in Volar ES (VES) and Dorsal ES (DES) of each patient.ResultsWe found ESs correlated with other activity scores: DAS28, CDAI, SDAI, HAQ. Correlations with clinical indices as CDAI and SDAI were stronger for VES than for DES. US discovered more synovitis than clinical examination.ConclusionVES is a suitable reflection of RA activity and volar US examination should accompany the dorsal one both in clinical practice and in clinical trials.

Aim: To evaluate the inter-and intraobserver agreement of a group of European rheumatologist ultrasonographers in grading musculoskeletal ultrasound videoclips posted on the Internet by using a non-sophisticated electronic environment. Methods: Forty short movie clips (less than 30 secs) were made available over the Internet to all participants. Normal and pathological RA hand joints and tendons were included in the movie clips. In the first phase 30 investigators from European countries were invited to evaluate the clips and to interpret/grade them. No instruction session was held prior to the initiation of the study. For synovitis the requested scoring system included 0 to3 grades and for tenosynovitis a binary variable 0/1; separate evaluations were performed for gray scale (GS) and Power Doppler (PD) examinations. In the second phase the responders were asked to grade the same clips in a different order without having access to their first grading scale. Light's k and Cohen's k were used to analyse inter-and intraobserver reliability. Results: Twenty two European rheumatologists agreed to finalise both study phases. Mean Cohen's κ for intraobserver reliability was 0.614/0.689 for tenosynovitis GS/PD and 0.523/0.621 for synovitis GS/PD. Light's k for interobserver reliability was 0.503 for tenosynovitis evaluation and 0.455 for global (synovitis and tenosynovitis) evaluation. Mean global overall agreement was 84.95% (90.2% for global synovitis). Conclusions: An over-the-net US evaluation and grading has shown moderate to good reliability. The results could be improved if a training session is added at the beginning of the study.

BackgroundMSUS helps the management of rheumatic diseases being able to show the level of tissue inflammation as Doppler signal. This signal might be scored in semi-quantitative and quantitative way. Several semi-quantitative scoring systems (SQS) have been developed but no one is subjective free. Quantitative Doppler score (QS) seems to be more objective (Terslev et al) being based on the computerized evaluation of the ratio between colored and non-colored pixels (CR). The present QS is based on the assessment of a single still image – usual the one with the highest Doppler signal; this approach does not exclude the subjective vulnerabilities (e.g. frame selection). We hypothesized that a Continuous quantitative assessment - CQS - (i.e. a quantitative assessment of all frames included in a video-loop) might be superior to single frame QS.ObjectivesTo test the ability of MS sonographers to identify the highest Doppler signal (highest CR) images from a group of frames extracted from the same loop. To test the reliability of a CQS method in rheumatoid arthritisMethods14 sonographers with high (4), medium (4) and basic (6) expertise in MSUS have participated in 3 phases of this project. In the 1st exercise we asked each participant to identify the frame with highest CR from a group of 4 frames (extracted from the same loop); the 4 frames had a CR decreasing in steps of 10%. The exercise included ten such groups. The 2nd exercise used a CR decreasing in steps of 2%. In the 3rd exercise the sonographers scored independently 10 MSUS video-clips and 10 static images of RA patients; the 0-3 SQS have been used. A blinded researcher analyzed each video and still image in CQS system twice; the average and the peak of CR have been noted for videos. CQS and SQS scores have been compared.ResultsIn 1st exercise the highest CR frame was identified in 7.5 (1.2) cases; in the 2nd exercise the performance was lower: 2.4 (2,1) cases out of 10. In both cases the agreement was poor. In the 3rd exercise the test-retest coefficients for CQS: 0.985 and 0.949 for average and, respectively, peak CRs. The average SQS scores correlated well with CQS CR (r=0.74 for average and r=0.76 for peak CR). The correlation was better for video clips (r=0.815) than for static images (r=0.546) - for average CR.ConclusionsContinuous quantitative assessment might be superior to single frame quantitative assessment in regular sonographers as the testers shown a moderate to poor performance in identification of the most significant picture. The test-retest performance and the higher correlation of CQS of video clips with SQS scores might recommend it as a reliable technique to assess Doppler loading in MSUS images.AcknowledgementsSf. Maria residents.Disclosure of InterestNone declared