Background: Rheumatoid arthritis (RA) is a systemic autoimmune disease that has a great impact on different joints, may result in their destruction and loss of function.Although the shoulder is affected in a large portion of patients with RA, it does not receive much attention during the follow up of RA. The precise diagnosis of shoulder pain in RA is a clinical challenge and benefits from a reliable imaging modality to detect its exact origin. Aim:To determine the diagnostic accuracy of ultrasound (US) in detecting shoulder joint pathologies in RA, considering magnetic resonance imaging (MRI) as the gold standard. Materials and Methods:This cross-sectional, observational study was carried out on 30 RA patients complaining of unilateral or bilateral shoulder pain. Patients were subjected to history taking, clinical shoulder examination, plain X-ray, US examination following a standardized protocol, and MRI. The results were correlated with each other. Results:In comparison with the MRI findings, US showed high accuracy in terms of sensitivity (Sn) and specificity (Sp) in supraspinatus tendinopathy (Sn 96.6%; Sp 93.3%), biceps tenosynovitis (Sn 87.5%; Sp 97.6%), subacromial-subdeltoid bursitis (Sn 72.7%; Sp 95.7%), humeral erosions (Sn 90.5%; Sp 97.3%), and acromioclavicular osteoarthritis (Sn 85.7%; Sp 95.7%). In terms of reliability, the agreement between US and MRI was almost perfect (κ = .9, P < .001). Conclusion:US may have a role as the initial imaging modality in RA patients with shoulder pain, as it is highly sensitive and specific in detecting different pathological abnormalities of the shoulder. K E Y W O R D S MRI, rheumatoid arthritis, shoulder, ultrasound | 2159 ABDELZAHER Et AL.

Background Rheumatoid arthritis (RA) is a systemic autoimmune polyarticular disease. Despite being commonly affected in RA, the ankle and foot do not receive much attention, particularly in early disease. The precise diagnosis of their involvement and its impact on health is a clinical challenge that requires accurate assessment. Aim To determine the role of ultrasound in evaluation of ankle and foot pathologies and assess its impact on functional activity in newly diagnosed RA patients. Methods The study was conducted on 152 RA patients and 52 healthy controls. Patients were subjected to history taking, clinical examination, and ultrasound scan. Impact on health was measured by health assessment questionnaire, as well as foot function index. Results In a cohort of patients with early RA with median duration of 1 month, tibialis posterior (TP) tenosynovitis (45.4%) was the most common pathology, followed by tibiotalar (TTJ) synovitis (39.8%), and peroneal tenosynovitis (39.1%). In terms of disease duration, TTJ (P = .001) foot pathologies were less common in early RA and tended to worsen over time, whereas TP (P = .048) and peroneal tenosynovitis (P = .011) were more common in early RA. In multivariate analysis TTJ, subtalar synovitis, forefoot pathologies, TP tenosynovitis, and Achilles enthesitis were found to be significant predictors of functional disability. The most important predictors of ankle pain were TTJ synovitis, TP tenosynovitis, peroneal tenosynovitis, and plantar fasciitis. Conclusion Ankle and foot involvement is a common issue of early RA, and it has a significant impact on quality of life. Ultrasound is a reliable tool for evaluating various abnormalities in this complex area, allowing for better management.

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Background:Rheumatoid arthritis (RA) is a chronic inflammatory disease that results in progressive destruction of structural components of the joints1.It commonly affects the shoulder leading to pain, tenderness and decreased range of motion2.Increased shoulder pain has been found to correlate strongly with disease severity3, however there is little information available in the literature regarding shoulder pathologies in asymptomatic RA patients.Objectives:To determine the prevalence of pathologies in asymptomatic shoulders in rheumatoid arthritis patients and role of ultrasound to detect it.Methods:A cross-sectional study including two groups, first group included 36 RA patients, meeting the ACR/EULAR classification criteria for RA with no shoulder complaints. The second group included 36 healthy control subjects of similar age groups and sex, with no shoulder complaints. They were recruited from rheumatology outpatient clinic in Mansoura University Hospital. Only asymptomatic shoulders of both groups were examined clinically by inspection, palpation and special tests, then examined by ultrasound using Toshiba Xario 200 machine with 13 MHz superficial probe including biceps tendon, subscapularis tendon, supraspinatus tendon, subacromial subdeltoid (SASD) bursa, infraspinatus tendon, posterior glenohumeral joint for effusion or synovitis, acromioclavicular joint and humeral head for erosions. Findings of both groups were compared to each other.Results:Asymptomatic shoulders in RA patients showed significant number of pathologies in 72% of the examined patients in comparison with healthy subjects (17%). According to frequency, humeral erosions were detected in 12 patients (33%), acromioclavicular osteoarthritis in 8 patients (22%), biceps tenosynovitis, supraspinatus tendinopathy, glenohumeral effusion in 6 patients (17%), subscapularis tendinopathy in 4 patients (11.%), SASD bursitis in 2 patients (6%), Infraspinatus tendinopathy in 1 patient (3%).The healthy group showed less number of pathologies including supraspinatus tendinopathy 3 (8%), acromioclavicular osteoarthritis 2 (6%), humeral erosions 1 (3%).Conclusion:A significant high rate of different pathologies can be present in shoulders of RA patients despite negative history and normal physical examination. Ultrasound can be used for early detection and better management before irreversible joint destruction.References:[1]Weishaupt D, Schweitzer ME (2004) MR imaging of septic arthritis and rheumatoid arthritis of the shoulder. Magn Reson Imaging Clin N Am 12:111–124[2]Varache S, Cornec D, Morvan J, et al. Diagnostic accuracy of acr/eular 2010 criteria for rheumatoid arthritis in a 2-year cohort. The Journal of rheumatology. 2011; 38(7): 1250-1257.[3]Van de Sande MA, De Groot JH, Rozing PM. Clinical implications of rotator cuff degeneration in the rheumatic shoulder. Arthritis care & research. 2008; 59(3): 317-324.Disclosure of Interests:None declared

BackgroundPatients with systemic sclerosis (SSc) are known to have an elevated risk for cardiovascular diseases. Approximately 20-25% of all SSc patients have permanently elevated C-reactive protein (CRP) levels [1,2]. Higher CRP levels are known to be associated with metabolic syndrome and diabetes mellitus (DM) (3), two factors that contribute to cardiovascular risk.ObjectivesTo investigate if permanently elevated CRP levels are associated with higher cardiovascular risk in a cohort of 65 patients with SSc.MethodsData analysis was carried out in R 4.1 using the packages dplyr, ggplot2, mice and MASS. 65 patients were enrolled in the study; 20 had permanently elevated CRP levels over two years before enrollment (CRP+ group), and 45 had normal CRP levels over 2 year prior enrollment (CRP- group). The following cardiovascular risk factors were selected as candidate predictors of CRP status: The Framingham Score, left and right carotid intima-media thickness (CIMT) on bilateral carotid ultrasound, pathological status of both carotids, presence of plaques in both carotids, number of plaques (0 if none), extent of largest plaque (0 if none), height, weight, body mass index (BMI), presence of arterial hypertension, history of smoking, packyears, DM type 2, chronic kidney disease, and a positive family history (cardiovascular event before the age of 65). We tested each variable as a bivariate predictor of CRP status in a logistic regression model. Subsequently, we used stepwise logistic regression based on the Akaike Information Criterion (AIC) to determine the optimal set of predictors. AIC evaluates model deviance in relation to the number of variables in the model, i.e., it can be used to find the optimal trade-off between model performance (predictive accuracy) and model complexity (number of predictors). Prior to logistic regression analysis, missing values in the dataset were replaced by means of multiple imputation.ResultsIn the bivariate logistic regression analyses (Table 1), only the Framingham Score and DM2 were identified as significant predictors, both with a positive weight, i.e., a higher Framingham Score and the presence of DM2 in a given patient were predictive of permanently positive CRP status, respectively. However, due to relatively low sample size, model sensitivity was 65%, and specificity was 86.7%.Cardiovascular risk factorORt-valuep-valueAge [years]1.000.34.734Framingham Score1.022.18.033CIMT right/ left1.28/ 1.200.84/ 0.86.402/.395CIMT pathological right/ left0.86/ 1.03-0.78/ 0.18.440/.860plaque right/ left1.16/ 1.191.32/ 1.50.191/.140number of plaques right/ left1.12/ 1.111.24/ 1.03.221/.307largest plaque right/ left [cm]1.08/ 1.011.62/ 0.30.110/.763height [m]1.200.29.772weight [kg]1.011.75.085BMI [kg/m²]1.021.76.082arterial hypertension1.030.24.808history of smoking1.141.12.269Packyears1.000.48.631DM 21.492.03.046chronic kidney disease1.120.68.499positive family history1.070.45.657ConclusionPermanently increased CRP levels are associated with higher Framingham scores and DM type 2 in SSc-patients. These findings are going to be validated in larger and longitudinal cohorts.References[1]Mitev A, et al. Arthritis Res Ther. 2019 Dec 2;21(1):262.[2]Muangchan C, et al. Arthritis Care Res (Hoboken). 2012 Sep;64(9):1405-14.[3]Chambers JC,et al. Circulation. 2001 Jul 10;104(2):145-50.Characters from table 1:Title: Results of bivariate logistic regression analyses.Footnotes: For each candidate predictor variable, the odds ratio (OR) along with its t-value and p-value are given. An OR greater than 1 indicates that a higher value in the respective candidate predictor variable (or response ‘yes’ for categorical candidate predictor variables) is associated with a higher probability of belonging to CRP-positive group.AcknowledgementsWe thank Dr. Marius Keute, an employee of Ortmann Statistics, for his support with statistical calculations.Disclosure of InterestsMohamed Gamal Abdelzaher: None declared, Daria Feldmann: None declared, Ursula Heilmeier: None declared, Ilona Jandova: None declared, Florian Kollert Employee of: Novartis, Reinhard Voll Speakers bureau: Novartis, Roche, Janssen, Galapagos, Pfizer, Astra Zeneca, Böhringer Ingelheim, Consultant of: Novartis, Roche, Janssen, Galapagos, Astra Zeneca, Böhringer Ingelheim, Grant/research support from: Novartis, Pfizer, BMS, Stephanie Finzel Speakers bureau: Novartis, Galapagos, Amgen, Abbvie, Paid instructor for: Novartis, Galapagos, Amgen, Abbvie, Consultant of: Novartis, Amgen, Novonordisk, Grant/research support from: Novartis, Sobi.

BackgroundSubclinical involvement of the ankles is common in rheumatoid arthritis (RA) and occurs even in patients in clinical remission[1]. Assessing the characteristics of ankle inflammation and its effect on the functional status will enable the clinician to target treatment interventions[2]. Ankle joint is underrepresented in many clinical, sonographic RA-scores, and there is little information available in the literature about ultrasound (US) evaluation of asymptomatic ankle pathologies in RA patients.ObjectivesTo assess the impact of US diagnosed subclinical ankle pathologies on the functional status of RA patients.MethodsThe study included 52 RA patients without ankle pain and 52 healthy age, gender matched controls. Ankle joints were examined clinically then by US using gray scale (GS) and Power Doppler (PD) including tibiotalar (TTJ), subtalar (STJ), talonavicular (TNJ), calcaneo-cuboid joints. In addition, tibialis anterior (TA), extensor hallucis longus (EHL), extensor digitorum longus (EDL), tibialis posterior (TP), flexor digitorum longus (FDL), flexor hallucis longus (FHL), peroneus longus, brevis and achilles tendons (AT), retrocalcaneal bursa (RCB) and plantar fascia (PF) were assessed. Functional capacity was measured using Health Assessment Questionnaire (HAQ) and Foot Function Index (FFI)ResultsData showed significantly more GSUS pathologies in the asymptomatic RA group than in the control group in TP (27.9% vs 3.8%) (P=0.043), FDL (3.8% vs 0%) (P=0.043), and peroneal tenosynovitis (26% vs 0%) (P<0.001), TTJ (23.1% vs 5.8%) (0.024) and TNJ synovitis (23.1% vs 3.8%) (P=0.024), AT tendinitis (19.2% vs 4.8%) (P=0.01), RCB bursitis (13.5% vs 1.9%) (P=0.002), STJ (13.5% vs 0%) (P=0.024), and calcaneo-cuboid joint synovitis (4.8% vs 0%) (P=0.024). Pathologies; see Figure 1. There was a trend to statistical significance of PDUS in TTJ and peroneal tendons in RA patients. Impaired functional activity as represented by higher HAQ and FFI scores was highly significantly associated to pathologies in TTJ, STJ, TNJ, AT, RCB, and PF; see Table 1.Figure 1.Asymptomatic ankle pathologies in RA by US. a) Tibiotalar synovitis, b) Tibialis posterior tenosynovitis)Table 1.Impact of subclinical ankle pathologies on functional status of RA patientsUltrasound pathologyHealth assessment questionnaireFoot function indexLowModerateHighPLowModerateHighPTibiotalar synovitis2(8.3%)15(62.5%)7(8.7%)0.051(4.2%)17(70.8%)6(25%)0.002Subtalar synovitis1(7.1%)6(42.9%)7(50%)0.0010(0%)7(50%)7(50%)<0.001Talonavicular synovitis3(12.5%)11(45.8%)10(41.7%)<0.0011(4.2%)15(62.5%)8(33.3%)<0.001Calcaneo-cuboid synovitis0(0%)1(20%)4(80%)<0.0010(0%)5(100%)0(100%)0.125TA tenosynovitis0(0%)0(0%)0(0%)……….0(0%)0(0%)0(0%)……….EHL tenosynovitis0(0%)0(0%)0(0%)……….0(0%)0(0%)0(0%)……….EDL tenosynovitis0(0%)0(0%)0(0%)……….0(0%)0(0%)0(0%)……….TP tenosynovitis4(14.3%)17(60.7%)7(25%)0.2334(14.3%)18(64.3%)6(21.4%)0.037FDL tenosynovitis2(50%)0(0%)2(50%)0.0180(0%)4(100%)0(0%)0.192FHL tenosynovitis0(0%)0(0%)0(0%)……….0(0%)0(0%)0(0%)……….Peroneal tenosynovitis6(23.1%)14(53.8%)6(23.1%)0.3165(19.2%)17(65.4%)4(15.4%)0.285Achilles tendinopathy3(15%)7(35%)10(50%)<0.0013(15%)11(55%)6(30%)0.016Retrocalcaneal bursitis2(14.3%)6(42.9%)6(42.9%)0.0090(0%)8(57.1%)6(42.9%)<0.001Plantar fasciitis2(20%)3(30%)5(50%)0.0052(20%)2(20%)6(60%)<0.001TA:tibialis anterior, EHL:extensor digitorum longus, EDL:extensor digitorum longus, TP:tibialis posterior, FDL:flexor digitorum longus, FHL:flexor hallucis longusConclusionAsymptomatic RA ankles exhibited higher number of US alterations in comparison to healthy individuals and significantly impaired the functional status of patients with RA. Foot and ankle joints should be considered for future scores in assessing disease activity and follow-up.References[1]Șerban, O., et alMedical ultrasonography, 21, 175-182.[2]Bruyn, G. A., et alJRheum, 46, 351-359.Acknowledgements:NIL.Disclosure of InterestsNone Declared.