Background:Enthesitis is defined as inflammation of the tendon inserting the bone encompassing the adjacent trabecular bone network, the fascia and surrounding soft tissues as the cartilage, the bursa and the fat pad. In enthesitis clinical examination alone is a method with significant limitations in terms of diagnostic accuracy and does not correlate strongly with imaging diagnostics (1,2).Ultrasound (US) is a widely used imaging technique in Rheumatology. But while learning curricula and standardization for joint US are available, other US techniques as vascular-, enthesis- or serosa-US gets usually less attention in rheumatologic US curricula. Though both OMERACT (4) and GRAPPA (3) have recently published qualitative and semi quantitative criteria in enthesitis US, few publications explicitly address the learning curves in these particular domain.Objectives:To describe the development of a tool to measure the learning curve for enthesitis US.Methods:3237 US images of 561 enthesis were obtained by one experienced ultrasonographer (PMA) in B- and color Doppler (CD) mode in longstanding psoriasis arthritis patients of different disease activity. Due to duplicity and poorer image quality 2115 images were eliminated. The remaining fully anonymized 1122 images (561 enthesis) were afterward implemented in a random multiple choice algorithm presenting a B-mode and a CD image of the same enthesis at the same time without timely limitation. Rating follows qualitative GRAPPA criteria as well as semiquantitative OMERACT criteria (3, 4). The enthesitis scoring application was than written in.NET/ C#, TypeScript and ReactJS and is hosted in Azure Cloud platform. The scoring is stored in a database allowing extraction to SPSS for statistical analysis.Results:The interface of the functional program is shown in image 1 (Screenshot). In a next step the program will be presented to different raters of different ultrasound experience (>10 years, 5-10 years, 1-5 years, <1 years). The program will be presented a multitude of times in different order to every rater to adjust for inter-rater reliability. Correlation between raters will be given to depict a learning curve on enthesitis ultrasound assuming the rater with the highest experience as gold standard.Image 1.Screenshot of grafical user interface of the scoring program.Conclusion:In this presentation we outline the successful development of a tool to measure the learning curve in enthesitis. We hypothesize that knowledge about the learning curve and inter-rater reliability in enthesitis US obtained by our tool might contribute to future US curricula, structured reporting and deep learning algorithms.References:[1]Achilles enthesitis defined by ultrasound is not associated with clinical enthesitis in patients with psoriatic arthritis, Brigitte Michelsen et al. RMD Open 2017;3[2]Ultrasonographic evaluation in psoriatic arthritis is of major importance in evaluating disease activity Brigitte Michelsen et al. Annals of the Rheumatic Diseases 12(2108-2113)[3]Development of a Preliminary Ultrasonographic Enthesitis Score in Psoriatic Arthritis -GRAPPA Ultrasound Working Group, Stephanie Tom et al. The Journal of Rheumatology; 4(384-390)[4]Reliability of a consensus-based ultrasound definition and scoring for enthesitis in spondyloarthritis and psoriatic arthritis: an OMERACT US initiative, Peter V Balint et al. Annals of the Rheumatic Diseases, 12(1730-1735)Disclosure of Interests:None declared
Background:In the last two decades ultrasound (US) has become a significant and valuable mode of diagnosing giant cell arteritis (GCA) in clinical practice (1). This is also reflected in the suggested expansion of the ACR 1990 criteria where imaging including US is equated with biopsy (2). Favorable sensitivity compared to biopsy has been shown and explained with the widespread uneven distribution of inflammation in cranial and extracranial arteries (3).Objectives:To explore the prevalence and distribution of inflammatory involvement in temporal, axillary and subclavian arteries in patients diagnosed with GCA at an ordinary rheumatology clinic.Methods:In this retrospective study we identified all patients diagnosed with GCA between 2006 and 2019. Since 2006 US has been used at the clinic to diagnose GCA. The vascular US examination was performed by two experienced ultrasonographers (HB, APD). The medical records were reviewed and data were collected using a predefined protocol including data collection for US at the time of diagnosis. Standard US procedure contained an assessment of both temporal arteries (superficial artery, frontal artery and parietal artery) in longitudinal and transversal planes with and without colordoppler mode. A positive US test was defined in presence of hypoechoic vessel wall thickening (halo sign). The axillary and subclavian arteries where assessed in B-mode and intima media thickness (IMT) was measured. A positive test was defined if IMT > 1 mm.Results:A total of 69 GCA patients (20 men and 49 women) with US performed at the time of diagnosis were identified. Among them, 67 (97.1%) patients met the suggested expansion ACR 1990 criteria. The mean age was 69.9 years. Detailed results for vasculitis distribution for the temporal artery with its branches and the axillary and subclavian arteries are shown in the table below. Positive US findings were recorded in 61 patients (88.4%). A total of 45 patients (65.2%) had a positive US test in the temporal artery and 41 patients (59.4%) in the extracranial arteries. Solely extracranial arteritis was observed in 18 patients (29.5%), 22 (36.0%) had exclusively temporal involvement. Involvement of both cranial and extracranial arteries was observed in 21 patients (34.4%). Only nine patients had positive findings at just one site. Five patients had isolated unilateral subclavian affection, and two patients had isolated unilateral frontal artery and superficial artery involvement each.Table.Positive US finding in 69 GCA patientsExtracranial arteriesTemporal arteriesSubclavianAxillarySuperficialParietalFrontalRight side1336192032Left side1327181832total1538222040total4145Conclusion:Our data highlights the importance and value of a complete US of cranial and extracranial arteries diagnosing GCA in daily clinical care. The data demonstrate the widespread nature of arterial affection in GCA and the fact that it is often more than one site that is affected. The spreading pattern was comparable to older studies in the respect of large vessel and multisite involvement.References:[1]Dejaco C. et al. Ann Rheum Dis. 2018;77:636-43.[2]Dejaco C et al. Rheumatology 2017;56:505-15.[3]Schmidt W A. Rheumatology. 2018;57;ii22-ii31.Disclosure of Interests:Peter Michael Andel Grant/research support from: Travel Grant from Vest Agder Legeforening, Norge, Serina Brådland: None declared, Vilde Haraldstad: None declared, Helle Bitter: None declared, Andreas Diamantopoulos: None declared, Glenn Haugeberg: None declared
Background:Giant cell arteritis (GCA) is the most common medium- and large vessel vasculitis in the elderly population. The diagnostic algorithm has changed in recent years in many institutions from temporal artery biopsy (TAB) to imaging based diagnosis (1). However, classification criteria that relied on TAB remained unchanged since 1990 (2). Reflecting the recent change in practice the Diagnostic and Classification Criteria for Vasculitis Study (DCVAS) group presented a draft classification criteria set for GCA. Endorsement by major scientific societies is currently pending (3).Objectives:To test the accordance of the GCA cohort of a single center in southern Norway between 2006 and 2018 to the draft DCVAS classification criteria in GCA.Methods:All patients diagnosed with GCA between 2006 and 2018 in our clinic were identified by international classification of disease (ICD) code for GCA (m31.5/m31.6) in the local electronic database. The draft DCVAS classification criteria were applied to all patients at the time of diagnosis, irrespective of the algorithm used to diagnose GCA. In the draft DCVAS classification criteria a score of 6 would be necessary to classify a patient as having GCA.Results:A total of 77 patients (55 female) diagnosed with GCA in the defined timespan were identified. Mean age was 69.2 years (57 – 83 years). As all patients were diagnosed with vasculitis and were older than 40 years of age, all patients met the compulsory criteria. The table 1 below shows the absolute number of patients that fulfilled the single criteria.The number of patients fulfilling the draft DCVAS classification criteria was 75 (97.4%). In the female cohort 96.4% patients finally diagnosed with GCA would be classified as having GCA as would 100% in the male cohort.Mean score was 12.4 (range 3-25). In 33.3 % of patients imaging was critical for classification. Laboratory findings were critical for classification in 9.3 %, head ache and scalp tenderness in 5.3%, temporal artery biopsy, morning stiffness and jaw claudication in 2.7%. The differentiation in possible and definite vasculitis in TAB did not change the result in any patient. Neither did sight-loss contribute to classify any patient. Five patients (6.5%) were diagnosed on clinical features and laboratory findings alone. Thirteen patients diagnosed with GCA and fulfilling DCVAS criteria had negative biopsies, three patients had an inconclusive TAB. Mean arterial biopsy length was 9 mm.Table 1.Draft DCVAS classification criteriaAboslute numberAge>40 years and vasculitis diagnosis (compulsatory)77New temporal headache+248Scalp tenderness+221Sudden visual loss+22Morning stiffness shoulder/neck+234Jaw claudication+222ESR > 50 mm/h or CRP > 10 mg/l+372TAB showing possible vasculitis+38TAB showing definite vasculitis+516Halo sign+561Bilateral axillary involvement+325PET showing aortitis+34Conclusion:A high percentage (97.4 %) of the patients diagnosed with GCA in our cohort fulfilled the draft DCVAS classification criteria. The high mean score (12.4) showed that DCVAS criteria did not depend heavily on single criteria. As diagnosis in our cohort was mainly based on ultrasound, imaging was the most critical item. This might be desirable as clinical features and laboratory markers should in general be confirmed by either imaging or TAB to ascertain diagnosis. However, five patients were solely diagnosed on clinical features and laboratory markers. Sight-loss did not contribute to classification in our cohort as most patients were seen in a fast-track clinic (FTC), but might be valuable in cohorts without FTC.References:[1]Dejaco C et al, Ann Rheum Dis. 2018;77(5):636-643[2]Hunder GG et al, Arthritis Rheum. 1990 Aug;33(8):1122-8[3]Merkel PA: oral presentation, American College of Rheumatology Annual Meeting 2018: October 19-24; 2018Disclosure of Interests:None declared
Background:Data addressing whether patients with psoriatic arthritis (PsA) are at increased risk of osteoporosis have been inconclusive (1). Most studies have reported cross sectional data, and there is a lack of longer-term studies. We have previously reported bone density data from an outpatient PsA clinic cohort (2). Herein, we present 5-year follow up data from that same cohort.Objectives:To explore longer-term change in bone mineral density (BMD) at femoral neck and spine (L1-4) in an outpatient PsA cohort.Methods:140 PsA patients were at baseline examined with dual energy x-ray absorptiometry (DXA) with measurements at femoral neck and spine (L1-4). Trained nurses performed the DXA scans. The DXA machines used at baseline (Lunar Prodigy) and at 5 year follow-up (Lunar iDXA) were stable over the measurement periods. Cross calibration using a spine phantom was performed between the two DXA machines (BMD of the old phantom in the new machine and the old phantom in the old machine, with 55 measurement over a time period of 2 weeks) had a difference of less than 1%. Demographic, disease measures and treatment data was collected at the same day or within 14 days to the date of DXA assessment. For group comparison, we used paired student t-test.Results:After 5 years, 114 PsA patients (50.4% women) were re-examined. Baseline mean (SD) was for age 51.4 (9.4) years, BMI 28.1 (3.4) kg/m2, disease duration 9.1 (6.7) years.Disease characteristics at baseline and follow-up presented as mean (SD) were: DAS28 3.05 (1.1) and 2.4 (0.8); CRP 4.3 (6.7) and 5.1 (12.2) mg/dl, ESR 14.9 (11.1) and 10.9 (12.9) mm/hr; mHAQ 0.40 (0.35) and 0.38 (0.37).The proportions of patients as baseline and follow up using conventional synthetic disease modifying anti-rheumatic drugs (DMARD) were 61.4% vs. 46.5%; for biological DMARDs 37.7% vs. 48.2%; for prednisolone 5.3% vs. 10.5%, for targeted osteoporosis medication 0.9% vs. 3.5%; for calcium and vitamin-D 11.4% vs. 26.3%. As shown in the table, no significant change in femoral neck and spine BMD and T-scores was found for the 114 patients. However for Z-scores (age and weight adjusted T-score) a significant increase was found both at femoral neck and lumbar spine. When gender was examined separately no significant reduction in bone density was found in men whereas in women a significant reduction during follow up was only found for right femoral neck BMD.Baseline5 yearsP valueBMD spine L1-41.22 (0.17)1.23 (0.17)0.13T-score spine L1-40.21 (1.42)0.32 (2.01)0.42Z-score spine L1-40.20 (1.32)0.78 (2.05)<0.001BMD Femoral neck L0.98 (0.14)0.97 (0.14)0.09T-score Femoral neck L-0.59 (1.15)-0.50 (1.02)0.14Z-score Femoral neck L-0.06 (1.02)0.37 (1.04)<0.001BMD Femoral neck R0.98 (0.14)0.98 (1.16)0.57T-score Femoral neck R-0.59 (1.10)-0.52 (0.94)0.22Z-score Femoral neck R-0.08 (1.02)0.35 (0.90)<0.001Conclusion:No reduction in BMD at femoral neck and spine was found in our PsA outpatient clinic cohort at baseline or over 5 years follow up. Rather, we found a statistically significant increase in age adjusted bone density (Z-score) both at femoral neck and spine over time. Our data thus adds evidence that PsA patients treated in ordinary clinical practice do not seem to be at an increased risk of developing osteoporosis.References:[1]Tai-li Chen, et al. Bone Mineral Density, Osteoporosis, and Fracture Risk in Adult Patients with Psoriasis and Psoriatic Arthritis: A systematic Review and Meta-Analysis of Observational Studies, J Clin Med 2020;9:3712[2]Agnete Malm Gulati, et al. Osteoporosis in psoriatic arthritis: a cross-sectional study of an outpatient clinic population. RMD Open 2018;4:1Acknowledgements:Research nurse Hanne Vestaby and osteoporosis nurses at -Division of Rheumatology, Kristiansand.Disclosure of Interests:Serina Brådland: None declared, Arthur Kavanaugh: None declared, Glenn Haugeberg Grant/research support from: Unrestricted Research Grant from Pfizer Norway.
BackgroundRecent years of progress in conventional and biologic disease-modifying anti-rheumatic drugs development and improved treatment strategies (treat to target) have yield in improved outcome in psoriatic arthritis (PsA) patients. [1,2]. Still, despite modern treatment and clinical monitoring methods, we might miss dimensions of disease burden outside our main focus including quality of life (QoL), which are of high importance from patients’ perspective.ObjectivesMain objective of this study was to explore how clinical aspects of disease activity and QoL measures will change in PsA patients in an ordinary outpatient clinic in Norway, followed for 5 years, in the biological treatment era.MethodsPsA patients fulfilling the CASPAR criteria visiting an outpatient clinic in Norway between January 2013 and February 2020 were consecutively included in the study. Data collection included variables for demographics, treatment, laboratory assessment of ESR and CRP, joint counts, disease activity score in psoriatic arthritis (DAPSA), global assessments – patient’s (PGA) and investigator’s (IGA), reported joint and global pain, patient reported outcomes (PROMs) regarding different aspects of quality of life (QoL), (MHAQ, RAID, QoL15D and reported fatigue level). Patients were analyzed at baseline and after 5-year follow-up period. Statistics included paired sample t test and McNemar test.ResultsAmong 140 PsA patients included at baseline, 114 (81.4%) were re-examined after 5 years. Mean age at baseline was 52 years (95%CI 50.3-53.7) and percentage of women was 50.7%. Proportion of patients treated with biologics increased from 32.9% to 39.5%, but the difference wasn’t statistically significant. During the 5 year follow up period most clinical disease activity measures decreased and QoL was maintained (Table 1).Table 1.Demographic data, clinical activity measures and patient reported outcomes regarding quality of life in PsA patients followed for 5 years. Values are mean (95CI) or number (%).Baseline (140)5-years follow up (114)pAge (years)52.0 (50.3, 53.7)56.3 (54.4, 58.3)Women71 (50.7%)56 (49.1%)Exercise >1h week62 (44.3%)59 (51.8%)0.28BMI (kg/m2)28.4 (27.5, 29.2)28.2 (27.3, 29.1)0.89Current smoker24 (17.1%)17 (14.9%)0.90Current bDMARD treatment46 (32.9%)45 (39.5%)0.65DAPSA18.6 (16.2, 21.0)12.8 (10.8, 14.8)<0.01TJC684.1 (3.2, 5.0)1.8 (1.3, 2.4)<0.01SJC660.7 (0.5, 0.9)0.3 (0.2, 0.4)<0.01ESR15.9 (13.9, 18.0)10.7 (7.8, 13.5)<0.01CRP4.9 (3.5, 6.3)5.3 (2.5, 8.2)0.41IGA (VAS 0-100)4.1 (3.2, 5.0)1.8 (1.3, 2.4)<0.01PGA (VAS 0-100)36.6 (32.5, 40.8)29.3 (25.0, 33.6)0.12Global pain (VAS 0-100)35.1 (31.2, 39.0)28.9 (24.4, 33.5)0.42Joint pain (VAS 0-100)33.8 (29.9, 37.8)27.5 (23.2, 31.9)0.31MHAQ (0-3)0.4 (0.4, 0.5)0.3 (0.3, 0.4)0.72RAID (0-10)3.5 (3.1, 3.9)3.2 (2.9, 3.6)0.41QoL15D (15-75)24.2 (23.1, 25.2)22.7 (21.6, 23.9)0.85Fatigue (VAS 0-100)47.8 (41.5, 54.2)39.1 (32.8, 45.4)0.16ConclusionIn our cohort of PsA patients after 5 years follow up disease activity was reduced and QoL maintained. Our data adds to the evidence that the burden of disease in PsA patients has decreased in the biologic treatment era however is still significant. Further improvement in pharmacological and non-pharmacological treatments in PsA patients is still needed.References[1]Coates LC, Moverley AR, McParland L, et al. Effect of tight control of inflammation in early psoriatic arthritis (TICOPA): a UK multicentre, open-label, randomised controlled trial. Lancet. 2015;386(10012):2489-2498. doi:10.1016/S0140-6736(15)00347-5[2]Coates LC, Helliwell PS. Treating to target in psoriatic arthritis: how to implement in clinical practice. Ann Rheum Dis. 2016;75(4):640-643. doi:10.1136/annrheumdis-2015-208617AcknowledgementsNurses and doctors from Division of Rheumatology at Sørlandet Hospital in Kristiansand, Norway contributed to data collection.Disclosure of InterestsNone declared
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