Search

Background Non-adherence to treatment could preclude reaching an optimal outcome. Thirty to 80% of patients with rheumatic and musculoskeletal diseases (RMDs) do not adhere to the agreed treatment. Objectives The objective was to establish points to consider (PtCs) for the prevention, screening, assessment and management of non-adherence to (non-)pharmacological treatments in people with RMDs. Methods An EULAR task force (TF) was established, and the EULAR standardised operating procedures for the development of PtCs were followed. The TF included healthcare providers (HCPs), comprising rheumatologists, nurses, pharmacists, psychologists, physiotherapists, occupational therapists and patient-representatives from 12 European countries. A review of systematic reviews was conducted in advance to support the TF in formulating the PtCs. The level of agreement among the TF was established by anonymous online voting. Results Four overarching principles and nine PtCs were formulated. The PtCs reflect the phases of action on non-adherence. HCPs should assess and discuss adherence with patients on a regular basis and support patients to treatment adherence. As adherence is an agreed behaviour, the treatment has to be tailored to the patients’ needs. The level of agreement ranged from 9.5 to 9.9 out of 10. Conclusions These PtCs can help HCPs to support people with RMDs to be more adherent to the agreed treatment plan. The basic scheme being prevent non-adherence by bonding with the patient and building trust, overcoming structural barriers, assessing in a blame-free environment and tailoring the solution to the problem.

Background and aimStriving for harmonisation of specialty training and excellence of care in rheumatology, the European League Against Rheumatism (EULAR) established a task force to develop points to consider (PtCs) for the assessment of competences during rheumatology specialty training.MethodsA systematic literature review on the performance of methods for the assessment of competences in rheumatology specialty training was conducted. This was followed by focus groups in five selected countries to gather information on assessment practices and priorities. Combining the collected evidence with expert opinion, the PtCs were formulated by the multidisciplinary task force, including rheumatologists, medical educationalists, and people with rheumatic and musculoskeletal diseases. The level of agreement (LoA) for each PtC was anonymously voted online.ResultsFour overarching principles and 10 PtCs were formulated. The overarching principles highlighted the importance of assessments being closely linked to the rheumatology training programme and protecting sufficient time and resources to ensure effective implementation. In the PtCs, two were related to overall assessment strategy (PtCs 1 and 5); three focused on formative assessment and portfolio (PtCs 2–4); three focused on the assessment of knowledge, skills or professionalism (PtCs 6–8); one focused on trainees at risk of failure (PtC 9); and one focused on training the trainers (PtC 10). The LoA (0–10) ranged from 8.75 to 9.9.ConclusionThese EULAR PtCs provide European guidance on assessment methods throughout rheumatology training programmes. These can be used to benchmark current practices and to develop future strategies, thereby fostering continuous improvement in rheumatology learning and, ultimately, in patient care.

The first EULAR provisional recommendations on the management of rheumatic and musculoskeletal diseases (RMDs) in the context of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), largely based on expert opinion, were published in June 2020. Since then, an unprecedented number of clinical studies have accrued in the literature. Several SARS-CoV-2 vaccines have been approved for population-wide vaccination programmes in EULAR-affiliated countries. Studies regarding vaccination of patients with (inflammatory) RMDs have released their first results or are underway.EULAR found it opportune to carefully review to what extent the initially consensus expert recommendations stood the test of time, by challenging them with the recently accumulated body of scientific evidence, and by incorporating evidence-based advice on SARS-CoV-2 vaccination. EULAR started a formal (first) update in January 2021, performed a systematic literature review according to EULAR’s standard operating procedures and completed a set of updated overarching principles and recommendations in July 2021. Two points to consider were added in November 2021, because of recent developments pertaining to additional vaccination doses.

Background:Up to 30% of Psoriasis (PsO) patients are prone to develop Psoriatic Arthritis (PsA). Agreement on how to identify PsO patients at risk of developing PsA is still lacking (1).Objectives:To identify predictors of PsA development in PsO patients through a systematic literature review (SLR) and meta-analyses (MA).Methods:MEDLINE, EMBASE and COCHRANE databases were searched (up to February 22nd, 2020). The PICO framework (population = PsO patients; intervention = clinical, environmental, imaging and genetic features; comparator = not applicable; outcome = PsA development) was used to design searches and define the eligibility of studies for inclusion. The MA focuses on 3 major features as possible predictors: i) PsO skin and nail involvement; ii) musculoskeletal (MSK) complaints; iii) inflammation and structural damage detected by imaging (Table 1). The sample estimates of the relative risk were pooled only when the studies were homogeneous in terms of cohort of patients, follow-up, study design and metrics.Results:4698 articles were screened for eligibility, 110 underwent a full reading and 29 were finally included. Figure 1 shows the study flow-chart for article selection. Though pooling was judge not appropriate, 5/7 prospective studies significantly support a predictive value of PsA development in patients with severe PsO (n=174635). While the predictive value of nail involvement is not well defined (n=2202), the pooled estimate from two cohort studies (n=474) supports nail pitting as predictor of PsA (RR=2.14 [1.32; 3.46]). Moving to the MSK complaints, the risk of developing PsA is about two times greater in PsO with than without arthralgia (pooled RR: 2.15 [1.16, 3.99]) within 2 years. Lastly, PsO patients with inflammation or structural damage detected by imaging are nearly four times more likely to develop PsA within 1-2 years (pooled RR from 4 cohort studies (n=247): 3.72 [2.12; 6.51]) (Table 1). The incidence rate of PsA varies from 1.34 to 5.9/100 p-ys in PsO and from 10.9 to 12.5/100 p-ys in PsOAr.Table 1.Studies reporting the major features as possible predictors of PsA development.PsO skin – severityPsO nail involvementPsO nail lesionsVariablesRelative Risk [95%CI]Follow-upWilson, 2009PsO nail involvementHRadjusted: 2.24 [1.26; 3.98]13.1±8.8 ysFaustini, 2015PASI score + PsO nail involvement/σ= -0.18[-0.84; 0.48] RR: 0.95 [0.37; 2.47]1.2±0.2 ysEder, 2016PASI score PsO nail involvement Type of PsO nail lesionsHR (>20vsHRunadjusted: 1.36 [0.76; 2.45] HRunadjusted: 2.21 [1.24; 3.92]4.1±2.1 ysEder, 2017PASI score + Type of PsO nail lesionsHRunadjusted: 1.05 [1.01; 1.09] HRunadjusted: 1.98 [0.83; 4.74]3.8±2.1 ysLewinson, 2017PsO severity defined from medicationsHRadjusted (moderate/severe vs mild): 5.02 [4.18; 6.04]5.1 ysEgeberg, 2018PsO severity defined from medicationsRR (severe vs mild): 1.31 [1.18; 1.46]18 ysElnady, 2019PASI score + PsO nail Involvement/σ= 0.79[-0.37; 1.95] RR: 1.43 [0.38; 5.31]2 ysGreen, 2020PsO severity defined from medicationRR (severe vs mild): 2.79 [2.49; 3.13]5.8 ysMSK-complaintsVariablesIncident-PsA casesFollow-upFaustini, 2015ArthralgiaRR: 1.98 [0.75; 5.19]1.2±0.2 ysEder, 2017ArthralgiaHRadjusted: 2.59 [1.15; 5.88]3.8±2.1 ysZabotti, 2019ArthralgiaRR: 4.44 [0.54; 36.72]1.6±0.5 ysSimon D, 2020ArthralgiaRR: 2.04 [0.86; 4.86]2.4±1.5 ysSub-clinical inflammation or structural damage detected by imagingVariablesIncident-PsA casesFollow-upFaustini, 2015MRIRR: 2.10 [0.75; 5.90]1.2±0.2 ysElnady, 2019MSK-USRR: 5.38 [1.17; 24.63]2 ysZabotti, 2019MSK-USRR: 6.86 [0.83; 56.63]1.6±0.5 ysSimon D, 2020HR-pQCTRR: 4.32 [1.96; 9.55]2.3±1.4 ysConclusion:Arthralgia and inflammation and/or structural damage detected by imaging are predictive features, likely prodromal, of PsA development. PsO severity and nail pitting are clinical manifestations related to PsA development.Figure 1.References:[1]Zabotti A, et al. Curr Rheumatol Rep. 2020 May 16;22(6):24. doi: 10.1007/s11926-020-00891-x.Disclosure of Interests:Alen Zabotti Speakers bureau: UCB, Novartis, Janssen, Paid instructor for: Amgen, Consultant of: Janssen, Orazio De Lucia Speakers bureau: Not relevant for this type of study, Consultant of: Not relevant for this type of study, Grant/research support from: Not relevant for this type of study, Garifallia Sakellariou Consultant of: AbbVie, Novartis, Alberto Batticciotto Speakers bureau: Not relevant for this type of study, Consultant of: Not relevant for this type of study, Grant/research support from: Not relevant for this type of study, Gilberto Cincinelli: None declared, Ivan Giovannini: None declared, Luca Idolazzi Speakers bureau: Eli Lilly, UCB, Celgene, MSD, Abbvie, Novartis, Paid instructor for: UCB, Gabriella Maioli Speakers bureau: Not relevant for this type of study, Consultant of: Not relevant for this type of study, Grant/research support from: Not relevant for this type of study, Ilaria Tinazzi Speakers bureau: Not relevant for this type of study, Consultant of: Not relevant for this type of study, Grant/research support from: Not relevant for this type of study, Daniel Aletaha Speakers bureau: not relevant for this type of study, Consultant of: not relevant for this type of study, Grant/research support from: not relevant for this type of study, Salvatore De Vita Consultant of: GSK, Roche, Grant/research support from: Not relevant for this type of study, Antonio Marchesoni Speakers bureau: not relevant for this type of study, Consultant of: not relevant for this type of study, Grant/research support from: not relevant for this type of study, Josef S. Smolen Speakers bureau: Not relevant for this type of study, Consultant of: Not relevant for this type of study, Grant/research support from: Not relevant for this type of study, Annamaria Iagnocco Speakers bureau: not relevant for this type of study, Paid instructor for: not relevant for this type of study, Consultant of: not relevant for this type of study, Grant/research support from: not relevant for this type of study, Dennis McGonagle Speakers bureau: ABBVIE, CELGENE, PFIZER, MSD, NOVARTIS, JANSSEN, UCB, GILEAD, BMS, LILLY, Grant/research support from: ABBVIE, CELGENE, PFIZER, MSD, NOVARTIS, JANSSEN, UCB, GILEAD, BMS, LILLY, Roberto Caporali Speakers bureau: Abbvie, Amgen, BMS, Celltrion, Galapagos, Gilead, Lilly, Pfizer, Roche, UCB, Sanofi, Fresenius Kabi, Samsung bioepis, MSD, Consultant of: Galapagos, Gilead, Lilly, Janssen, MSD

No abstract available.

The last decade witnessed the ascendancy of rheumatology to become one of the most dynamic and progressive across the fields of medicine. During the COVID-19 pandemic our discipline emerged at the forefront of molecular medicine with the rapid uptake of immune-modulatory therapeutics and depth of immune pathogenesis understanding contributing fundamentally to the COVID-19 response. The European Alliance of Associations for Rheumatology (EULAR) played a fundamental and vital role in this response in guiding rheumatic and musculoskeletal disease (RMD) therapeutics, vaccine use and even treatment innovations in the context of COVID-19 itself. Given this remarkable contribution, it is timely to reflect on EULAR—what is it and for what does it stand? At its core, EULAR represents people with RMDs, including their national societies, health professionals in rheumatology and scientific societies of rheumatology across the European nations. Our mission is to reduce the burden of RMDs on individuals and society and improve the treatment and prevention of RMDs. In this message from the new EULAR President and Steering Group, we present the most relevant activities of EULAR, its strategic aims and the concept of the EULAR family, a fantastic team of people working together across the three pillars of medical, health professional and patient societies.

Background/objectivesTo maintain and optimise the quality of care provided by health professionals in rheumatology (HPRs), adequate educational offerings are needed. This task force (TF) aimed to develop evidence-based recommendations for the generic core competences of HPRs, with specific reference to nurses, physical therapists (PTs) and occupational therapists (OTs) to serve as a basis for their postgraduate education.MethodsThe EULAR standardised operating procedures for the development of recommendations were followed. A TF including rheumatologists, nurses, PTs, OTs, patient-representatives, an educationalist, methodologists and researchers from 12 countries met twice. In the first TF meeting, 13 research questions were defined to support a systematic literature review (SLR). In the second meeting, the SLR evidence was discussed and recommendations formulated. Subsequently, level of evidence and strength of recommendation were assigned and level of agreement (LoA) determined (0–10 rating scale).ResultsThree overarching principles were identified and 10 recommendations were developed for the generic core competences of HPRs. The SLR included 79 full-text papers, 20 of which addressed the competences, knowledge, skills, attitudes and/or educational needs of HPRs from multiple professions. The average LoA for each recommendation ranged from 9.42 to 9.79. Consensus was reached both on a research and educational agenda.ConclusionEvidence and expert opinion informed a set of recommendations providing guidance on the generic core competences of HPRs. Implementation of these recommendations in the postgraduate education of HPRs at the international and national level is advised, considering variation in healthcare systems and professional roles.

Dear Editor, We read with interest the correspondence by Chen et al 1 about our recent article on the comparison of clinical, laboratory and artificial intelligence–radiological findings in patients with lung involvement either from macrophage activation syndrome (MAS), a secondary form of haemophagocytic lymphohistiocytosis (HLH) or severe coronavirus disease 2019 (COVID-19).2 Age is one of the most common confounding factors in any observational study since it is associated with an increased risk of comorbidities, which may influence the outcome. In our study, the matching for age was not reliable because of higher prevalence of severe COVID-19 in elderly patients, who were admitted to intensive or subintensive care units of our hospital. These results mirror what was already observed in other observational studies,3 4 in which the incidence and severity of COVID-19 are generally higher in elderly patients due to higher frequency of comorbidities, increased frailty and immunosenescence.5 Conversely, MAS complicating adult-onset Still’s disease (AOSD), as patients assessed in our study, usually affects young adults.6 Considering the scientific debate behind our study,2 about the possibility that severe COVID-19 could be considered or not part of HLH spectrum, the age of occurrence may further differentiate the clinical pictures between these diseases. Furthermore, Chen et al 1 questioned the use of Yamaguchi criteria in classifying AOSD patients .7 Although …

ObjectivesDactylitis is one of the most typical features of psoriatic arthritis (PsA), with a high lifetime prevalence and inclusion in PsA clinical indices. Musculoskeletal ultrasonography (Msk-US) can readily detect inflammatory involvement of finger anatomical structures particular to dactylitis and monitor therapeutic effects. In this study, we aim to identify the characteristic lesions in PsA dactylitis of the hands, assess the reliability of Msk-US in scoring those lesions and develop a DACTylitis glObal Sonographic (DACTOS) score.MethodsAfter a systematic literature review on the use of Msk-US in PsA dactylitis, 12 rheumatologists participated in a three-round Delphi procedure and consensus meeting to agree on the sonographic elementary lesions characterising dactylitis and on the composition of a global sonographic score. Then, a web-based and a patient-based intra-rater and inter-rater reliability exercise was performed to assess those lesions included in the score.ResultsDACTOS score was obtained by summing the scores of each lesion selected in the Delphi survey: subcutaneous soft tissue oedema, flexor tenosynovitis, peritendon extensor inflammation and synovitis. The DACTOS score ranges from 0 to 25. In the reliability exercises, we obtained moderate-to-excellent agreement for the sonographic lesions included in the score.ConclusionsThe novel DACTOS score is a reliable measure to interpret the multiple characteristic sonographic features of dactylitis. The DACTOS score provides a useful global analysis of dactylitis of the hand and can represent a support to clinical diagnosis as well as a useful tool for the management and research in patients with PsA with dactylitis.

The catastrophic outbreak of acute respiratory distress syndrome induced by SARS-CoV-2 (the coronavirus disease 2019, COVID-19) has strongly confirmed the important role of systemic hyperinflammation, independently of the trigger, as a major cause of death.1 In fact, accumulating evidence suggests that a subgroup of patients with severe COVID-19 is burdened by a cytokine storm syndrome, an overwhelming systemic inflammation with a massive release of pro-inflammatory cytokines. As reported in 150 patients in Wuhan, China, a subset of patients with COVID-19 are characterised by raised levels of ferritin, which identified those patients at higher risk of poor outcome (1297.6 ng/mL in non-survivors compared with 614.0 ng/mL in survivors).1 Although the amplitude of ferritin elevation is not comparable, this finding may resemble what is observed in diseases included under the umbrella of the hyperferritinaemic syndrome.2 This syndrome includes macrophage activation syndrome (MAS), systemic juvenile idiopathic arthritis, adult-onset Still’s disease (AOSD) and catastrophic anti-phospholipid syndrome, which are burdened by severe clinical picture and high mortality rate.2 Ferritin, the common denominator of all these diseases, is an iron storage protein comprising 24 subunits of two types, heavy (FeH) and …

Women are generally less represented as first author among original medical researches and clinical guidelines. Indeed, women are first authors in only 30% of clinical guidelines published in high impact medical journals.1 2 Nevertheless, the trend seems to be improving over the last 20 years but it has plateaued in recent years.3 It is not known if a comparable under-representation occurs also in rheumatological guidelines. We have conducted a bibliometric analysis to evaluate the representation of female authors in rheumatological guidelines and recommendations over a period of time between 2004 and 2019. We searched PubMed for guidelines and recommendations published in English in the rheumatological field from 1 January 2004 to 1 January 2019. We included …

We thank Dr Coiffier and colleagues for their interesting letter in which they suggest that damages of major salivary glands (SG) might be associated with cryoglobulinemic vasculitis and lymphoma in primary Sjogren’s syndrome. The authors raise the question whether the ultrasonographic (US) features of the salivary glands [our proposed novel ultrasound scoring system] could be used as the new prognostic markers for cryoglobulinemic vasculitis and lymphoma in patients with Sjogren’s syndrome.1 In their recent study of different US scoring systems in 97 sicca syndrome patients, Coiffier et al found three B-cell lymphomas in the primary Sjogren’s syndrome (pSS) group and three, two, and one patient with …

Background:Imaging has been extensively used for the Calcium Pyrophosphate Deposition Disease (CPPD) diagnosis but the prevalence of joint calcifications at imaging in CPPD patients has not been thoroughly assessed.Objectives:This systematic literature review (SLR) is aimed to estimate the prevalence of calcium crystal deposition in peripheral joints by imaging in suspected or definite CPPD patients to establish relevant joints for CPPD monitoringMethods:After defining PICOs, Pubmed and Embase were searched from inception to October 2020 for identifying studies that evaluated the use of Conventional Radiography (CR), Ultrasound (US), Computed Tomography (CT) and Dual Energy Computed Tomography (DECT) in detecting calcifications at peripheral joints in patients with defined or probable CPPD. Search strategies based on MeSH terms and free text were applied. Six reviewers independently screened titles and abstracts, eligible article full texts were evaluated for inclusion and data extraction.Results:The SLR identified 1149 manuscripts. 524 papers entered in the full text evaluation and 181 articles were finally included. Considering excluded abstracts and full texts, 23 and 17 were excluded as duplicate, 156 and 9 for language, 171 and 48 for population, 171 and 20 for intervention, 57 and 117 for outcome, 47 and 70 for study type and 76 for full text unavailability. Among included, 41 papers considered patients with definite CPPD with a total population of 1239 patients, 908 cases and 331 controls and 140 papers referred to patients with suspected CPPD with a total population of 26785 patients, 2896 affected by CPPD and 23889 controls. The results about all joints are summarized in the Table 1. In patients with definite diagnosis, knee and wrist are the joints with the highest prevalence of calcifications at all imaging types, followed by hip and acromion-clavicular joint while in patients with suspected CPPD, the knee is the most prevalent followed by the wrist, hip and ankle (only sites with more than 50 patients assessed considered). The hand joints are characterized by CPPD lowest prevalence at imaging. Bilateral imaging findings varies depending on the technique used, the site and the patient’s type.Table 1.Definite CPPD DiagnosisKNEEWRISTHANDELBOWSHOULDERACHIPANKLEFOOTTMXRImaging positive cases/all cases330/584 57%214/409 52%43/158 27%54/212 25%65/249 26%37/84 44%140/293 48%30/255 12%15/59 25%0Cases positivebilaterally99/146 68%30/79 38%0/104/12 33%2/2 100%9/17 53%7/10 70%7/10 70%00USImaging positive cases/all cases155/252 62%86/118 75%4/42 9%2/2 100%0/304/30 13%47/80 59%30/255 12%15/59 25%0Cases positivebilaterally83/96 86%33/47 70%1/ 4 25%003/ 4 75%29/47 62%7/10 70%00CTImaging positive cases/all cases41/50 82%22/28 78%00000000Cases positivebilaterally27/30 90%000000000DECTImaging positive cases/all cases8/10 80%9/10 90%1/1 100%0000000Cases positivebilaterally001/1 100%0000000Suspected CPPD diagnosisKNEEWRISTHANDELBOWSHOULDERACHIPANKLEFOOTTMXRImaging positive cases/all cases1989/2442 81%549/1024 54%98/602 16%29/72 40%75/185 41%27/31 87%322/887 36%56/116 48%24/42 57%0Cases positive bilaterally611/1068 57%209/334 63%64/85 75%22/23 96%41/46 89%0/294/196 48%44/53 83%18/19 95%0USImaging positive cases/all cases241/261 93%125/185 68%2/39 5%1/1 100%4/12 33%02/2 100%27/78 35%8/37 22%0Cases positivebilaterally4/9 44%74/93 80%00000000CTImaging positive cases/all cases019/23 83%002/2 100%02/2 100%001/1 100%Cases positivebilaterally0000000001/1 100%DECTImaging positive cases/all cases1/1 100%2/2 100%00000000Cases positivebilaterally1/1 100%000000000Table 1 For each joint, are summarized the ratio between positive joints and overall evaluated joints and the ratio between the joints positive bilaterally and overall joints evaluated bilaterally.AC Acromion Clavicular, TM temporo mandibularConclusion:According to the results of this SLR, knees and wrists could be the sentinel joints for CPPD detection by imaging.Disclosure of Interests:None declared.

Background:Synovial fluid analysis (SFA) via compensated polarized light microscopy is still considered the gold standard for the identification and diagnosis of Calcium Pyrophosphate Deposition disease (CPPD)-related arthropathies[1], but very few studies have been published about its diagnostic accuracy.Objectives:The aim of this study was to evaluate the accuracy of SFA in the identification of calcium pyrophosphate dihydrate (CPP) crystals compared to microscopic analysis of joint tissues as the reference standard.Methods:This is an ancillary study of an international, multicentre cross-sectional study performed by the CPPD subgroup of the OMERACT Ultrasound working group[2]. Consecutive patients with knee osteoarthritis (OA) waiting for total knee replacement surgery were enrolled in the study from 2 participating centres, Mexico and Romania. During surgical procedures synovial fluid (SF), menisci and hyaline cartilage were collected and analysed within 48 hours after surgery under transmitted light microscopy and compensated polarised light microscopy for the presence/absence of CPP crystals. All slides were analysed by expert examiners on site, blinded to other findings. A dichotomic score (absence/presence) was used for scoring both SF and tissues. Microscopic analysis of knee tissues was considered the gold standard. Sensitivity, specificity, accuracy, positive and negative predictive values (PPV and NPV) of SFA in the identification of CPP crystals were calculated.Results:15 patients (53% female, mean age 68yo ± 8.4) with OA of grade 3 or 4 according to Kellgren-Lawrence scoring were enrolled. 12 patients (80%) were positive for CPP crystals at SFA and 14 (93%) at tissues microscopic analysis. Among 12 SFA positive patients, all were positive for CPP crystals in either medial or lateral meniscus, and 11 were positive in both; 10 patients were positive at the hyaline cartilage, and all 10 were also positive for at least one meniscus. Regarding the 3 SFA negative patients, only one had no crystals in the examined tissues, while the other 2 patients had CPP crystals in both menisci and hyaline cartilage. The overall diagnostic accuracy of SFA compared to histology analysis for CPPD was 87%, with a sensitivity of 86% and a specificity of 100%, the PPV was 100% and the NPV was 33% (Table 1).Table 1.sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of synovial fluid analysis compared to the reference standard. CI: Confidential Interval. SF: synovial fluid, in parentheses: numerators and denominators for all percentages provided.SensitivitySpecificityPPVNPVAccuracySF analysis86% (12/14)100% (1/1)100% (12/12)33% (1/3)87% (13/15)(0.65-0.99) CI 95%(0.0-0.25) CI 95%(0.65-0.99) CI 95%(0.0-0.25) CI 95%Conclusion:SFA demonstrated to be an accurate test for the identification of CPP crystals in patients with advanced OA. However, is not always feasible and carries some risks for the patient. Considering the availability of validated imaging techniques for the detection of CPPD, such as US, SFA could be used in those patients where imaging and clinical data are not definitely confirmatory of the disease.References:[1]W. Zhang et al., ‘European League Against Rheumatism recommendations for calcium pyrophosphate deposition. Part I: terminology and diagnosis’, Ann Rheum Dis, vol. 70, no. 4, pp. 563–570, Apr. 2011, doi: 10.1136/ard.2010.139105.[2]G. Filippou et al., ‘Criterion validity of ultrasound in the identification of calcium pyrophosphate crystal deposits at the knee: an OMERACT ultrasound study’, Ann Rheum Dis, p. annrheumdis-2020-217998, Sep. 2020, doi: 10.1136/annrheumdis-2020-217998.Disclosure of Interests:None declared.

Background:Conventional Radiography (CR) has been widely used in the assessment of knee chondrocalcinosis (CC) and is still considered one of the most important diagnostic methods for the diagnosis. However, there are no studies on the reliability of CR for CC.Objectives:To assess the reliability of CR of the knee in the assessment of chondrocalcinosis (CC).Methods:This is an ancillary study of the Criterion Validity of Ultrasound in Calcium Pyrophosphate Deposition Disease (CPPD) study [1]. Consecutive patients with knee osteoarthritis (OA) that were planned for total knee replacement surgery were enrolled in 4 centres from Romania, Italy, USA and Mexico. All patients underwent CR of the knees taken maximum 6 months before surgery, in posterior-anterior weight baring and lateral projections. DICOM files of the radiographs were retrieved, anonymised and read independently by two musculoskeletal radiologists with experience in microcrystalline arthropathies. Each reader performed a second evaluation 3 weeks after the first one to calculate the inter- and intra-reader agreement. For each patient a dichotomic score was assigned (absence/presence of CC) at the level of the medial and lateral menisci, tibiofemoral hyaline cartilage, quadriceps and patella tendons, synovial membrane/joint capsule. The definitions of the ACR/EULAR taskforce for identification of CPPD in conventional radiography were used in this study [paper in preparation]. According to these definitions CPPD in CR appears as “linear or punctate opacities in the region of fibro- or hyaline articular cartilage/synovial membrane or joint capsule/within tendons or entheses that are distinct from denser, nummular radio-opaque deposits due to basic calcium phosphate deposition”. Cohen’s kappa was used to calculate the agreement between the two readers.Results:We enrolled 33 patients with knee OA (60.6% female, mean age 69yo ± 8). The kappa values of the inter-reader and intra-reader agreement in the various sites of the knee are indicated in Table 1. Inter-reader agreement was substantial at the level of both menisci but only moderate or fair at the other sites of assessment. This had a negative impact on the overall evaluation of the knee joint that proved to be unreliable (k of 0.16 – none to slight agreement) if all anatomical structures are included for assessment, and moderately reliable (kappa 0.41) when both menisci and hyaline cartilage are considered. On the other hand, intra-reader kappa values were substantial or higher in all sites (except for synovial membrane/joint capsule for one reader). The striking difference of the intra-reader compared to the inter-reader kappa values, highlight a different interpretation and application of the definitions used for most of the sites with the exception of the menisci.Table 1.kappa values for intra- and inter-reader agreement. Values from 0.01–0.20 are considered as none to slight agreement, 0.21–0.40 as fair, 0.41– 0.60 as moderate, 0.61–0.80 as substantial, and 0.81–1.00 as almost perfect agreement.Medial meniscusLateral meniscusHyaline cartilageQuadriceps tendonPatellar tendonCapsule/ synoviaMenisci + cartilageEntire jointInter-reader0.670.710.340.47NA0.370.400.17Intra-reader 1st assessor0.670.900.840.65NA(insufficient number of categories)0.530.710.76Intra-reader 2nd assessor10.801110.910.860.94Conclusion:CR has been extensively used for diagnosis of OA and CPPD. The results of our study raise some concerns on the reliability of CR in identification of CPPD. Assessment of calcium crystals at the menisci level should be used for identification of CC as other sites of the knee seem to present low reliability.References:[1]Filippou G et al. Criterion validity of ultrasound in the identification of calcium pyrophosphate crystal deposits at the knee: an OMERACT ultrasound study. Ann Rheum Dis 2020. doi:10.1136/annrheumdis-2020-217998Disclosure of Interests:None declared.

Background:Classification criteria for calcium pyrophosphate deposition disease (CPPD) will facilitate clinical research on this common crystalline arthritis. ACR/EULAR are jointly sponsoring development of CPPD classification criteria using a multi-phase process.Objectives:To report preliminary results from the first two phases of a four-phase process for developing CPPD classification criteria.Methods:CPPD classification criteria development is overseen by a 12-member Steering Committee. Item generation (Phase I) included a scoping literature review of five literature databases and contributions from a 35-member Combined Expert Committee and two Patient Research Partners. Item reduction and refinement (Phase II) involved a Combined Expert Committee meeting, discussions among Clinical, Imaging, and Laboratory Advisory Groups, and an item rating exercise to assess the influence of individual items toward classification. The Steering Committee reviewed the modal rating score for each item (range -3 [strongly pushes away from CPPD] to +3 [strongly pushes toward CPPD]) to determine items to retain for future phases of criteria development.Results:Item generation yielded 420 items (312 from the literature, 108 from experts/patients). The Advisory Groups eliminated items they agreed were unlikely to distinguish between CPPD and other forms of arthritis, yielding 127 items for the item rating exercise. Fifty-six items, most of which had a modal rating of +/- 2 or 3, were retained for future phases (see Table 1). As numerous imaging items were rated +3, the Steering Committee recommended focusing on imaging of the knee, wrist, and one additional affected joint for calcification suggestive of CPP crystal deposition.Conclusion:The ACR/EULAR CPPD classification criteria working group has adopted both data- and expert-driven approaches, leading to 56 candidate items broadly categorized as clinical, imaging, and laboratory features. Remaining steps for criteria development include domain establishment, item weighting through a multi-criteria decision analysis exercise, threshold score determination, and criteria validation.Table 1.Categories of items retained for future phases of classification criteria developmentAge in decade at symptom onsetAcute inflammatory arthritis (e.g. knee, wrist, 1st MTP joint*)Recurrence and pattern of joint involvement (e.g. 1 self-limited episode, >1 self-limited episode)Physical findings (e.g. palpable subcutaneous tophus*, psoriasis*)Co-morbidities and family history (e.g. Gitelman disease, hemochromatosis, familial CPPD)Osteoarthritis location and features (e.g. 2nd or 3rd MCP joint, wrist)Synovial fluid findings (e.g. CPP crystals present, CPP crystals absent on 1 occasion* or 2 occasions*, monosodium urate crystals present*)Laboratory findings (e.g. hypomagnesemia, hyperparathyroidism, rheumatoid factor*, anti-CCP*)Plain radiograph: calcification in regions of fibro- or hyaline cartilage+Plain radiograph: calcification of the synovial membrane/capsule/tendon+Conventional CT: calcification in regions of fibro- or hyaline cartilage+Conventional CT: calcification of the synovial membrane/capsule/tendon+Ultrasound: CPP crystal deposition in fibro- or hyaline cartilage+Ultrasound: CPP crystal deposition in synovial membrane/capsule/tendons+Dual-energy CT: CPP crystal deposition in fibro- or hyaline cartilage+Dual-energy CT: CPP crystal deposition in synovial membrane/capsule/tendon+*Potential negative predictor +Assessed in the knee, wrist, and/or 1 additional affected jointDisclosure of Interests:Sara Tedeschi Consultant of: NGM Biopharmaceuticals, Tristan Pascart: None declared, Augustin Latourte Consultant of: Novartis, Cattleya Godsave: None declared, Burak Kundaki: None declared, Raymond Naden: None declared, William Taylor: None declared, Nicola Dalbeth Speakers bureau: Abbvie and Janssen, Consultant of: AstraZeneca, Dyve, Selecta, Horizon, Arthrosi, and Cello Health, Tuhina Neogi: None declared, Fernando Perez-Ruiz: None declared, Ann Rosenthal: None declared, Fabio Becce Consultant of: Horizon Therapeutics, Grant/research support from: Siemens Healthineers, Eliseo Pascual: None declared, Mariano Andrés: None declared, Thomas Bardin: None declared, Michael Doherty: None declared, Hang Korng Ea: None declared, Georgios Filippou: None declared, John FitzGerald: None declared, Marwin Gutierrez: None declared, Annamaria Iagnocco: None declared, Tim Jansen Speakers bureau: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Consultant of: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Minna Kohler Speakers bureau: Lilly, Consultant of: Novartis, Frederic Lioté: None declared, Mark Matza: None declared, Geraldine McCarthy Consultant of: PK Med, Roberta Ramonda: None declared, Anthony Reginato: None declared, Pascal Richette: None declared, Jasvinder Singh Speakers bureau: Simply Speaking, Consultant of: Crealta/Horizon, Medisys, Fidia, UBM LLC, Trio health, Medscape, WebMD, Adept Field Solutions, Clinical Care options, Clearview healthcare partners, Putnam associates, Focus forward, Navigant consulting, Spherix, Practice Point communications, Francisca Sivera: None declared, Alexander So: None declared, Lisa Stamp: None declared, Janeth Yinh: None declared, Chio Yokose: None declared, Robert Terkeltaub Consultant of: Sobi, Horizon Therapeutics, Astra-Zeneca, Selecta, Grant/research support from: Astra-Zeneca, Hyon Choi: None declared, Abhishek Abhishek Consultant of: NGM Biopharmaceuticals.

Background:Health professionals play an important role in the care for people with rheumatic and musculoskeletal diseases. In order to improve and maintain the quality of their work, appropriate professional education is needed. EULAR has developed several educational products and activities specifically targeted at Health Professionals in Rheumatology (HPR), but particularly in Eastern European countries, their uptake is limited. The overarching aim of a EULAR project (named HEE4ALL: Health professionals Education in Eastern European countries for All) is to develop and execute implementation strategies for EULAR educational activities in 3 eastern European countries.Objectives:The aim of the present analysis was to identify barriers and facilitators for the uptake of EULAR educational activities among HPR in Eastern European countries.Methods:First, a questionnaire was sent to representatives of national health professionals’ or patients’ organization in 17 Eastern European countries, in order to determine their eligibility to participate in the implementation project. Eligibility criteria were: Having a national HPR organization; Willing and able to compose a team with HPR, Patients, and Rheumatologists; and Interested to participate in the project. Selected countries (minimum 3) were requested to set up a national implementation team, and conduct a national, electronic survey among HPR on anticipated barriers and needs regarding educational activities. The survey included the following elements: a. characteristics of the responding HPRs; b. Familiarity with EULAR educational offerings; c. Anticipated barriers and facilitators (score 0=no barrier at all to10 very important barrier); d. Ability to pay for the HPR online course.Results:Representatives from 10/17 Eastern European countries responded to the first questionnaire, with 3 countries meeting the selection criteria: Hungary, Serbia and Turkey. Subsequently, 216 (H:106, S:42 and T:68) HPR completed the 3 national surveys. In all 3 countries, the majority of the respondents was female (93.1%), and nurse (70.8%) or physical therapist (19.0). Familiarity with EULAR educational offerings was poor, with the lowest proportions of HPR being familiar with postgraduate face-to-face courses (13.9%), educational visits (19.0%) and the EULAR online course for HPR (25.0%). The highest ranked barriers in all 3 countries included the costs of EULAR annual congress, the costs of the EULAR HPR online course and a lack of mastery of English language.The maximum amount of money HPR were able to pay for the EULAR online course was on average €66, €29 and €83 in Hungary, Serbia and Turkey, respectively.Conclusion:Based on a survey in 3 Eastern European countries, it appears that familiarity with EULAR educational offerings is suboptimal. However, when HPR are aware of the educational offerings, their costs and a lack of mastery of the English language seem to be the most important barriers for participation. Based on these results, the 3 national teams developed implementation plans during a 2-day meeting (October 2019). The implementation plans are now executed and a process and effect evaluation is planned by November, 2020.Acknowledgments:Supported by EULAR; Project HPR 042Disclosure of Interests:Leti van Bodegom-Vos: None declared, T.P.M. Vliet Vlieland: None declared, Loreto Carmona Grant/research support from: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution), Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Andrea Domjan: None declared, Alzbeta Goehmann: None declared, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi, Marija Kosanovic: None declared, Rikke Helene Moe: None declared, Wilfred Peter: None declared, Marija Segrt: None declared, Eda Tonga: None declared, Codruta Zabalan: None declared

Background:The eRA (evolving the management of RA) programme was initiated in Europe to provide practical educational tools that address unmet needs in the management of rheumatoid arthritis (RA). Several eRA tools – covering early access to care, management of comorbidities, treat-to-target strategies, and patient empowerment – are available to the rheumatology community. Through ongoing activities, the eRA Steering Committee (SC) identified a need for tools on non-pharmacological management of RA.Objectives:To improve accessibility to eRA tools for rheumatology professionals; to review the evidence base of non-pharmacological interventions to create new eRA resources that may support management decisions.Methods:A web platform providing information on eRA programme and tools was developed in 2019. The platform collects survey-based metrics to quantify perception of eRA and use of eRA tools in clinical practice. Platform and tools are translated to further support access and use across Europe.To address unmet needs in non-pharmacological patient management, the eRA SC reviewed the core literature on agreed priority interventions, including physical activity, diet, patient education and self-management, psychosocial interventions, occupational therapy and orthotics, hand exercises, and hydrotherapy/balneotherapy. Available evidence for each intervention was assessed and graded according to the Oxford Centre for Evidence-based Medicine Levels of Evidence.Results:The eRA web platform is now live in 3 countries (www.evolvingthemanagementofRA.com), hosting translated copies of the eRA tools, with additional countries launching throughout 2020.From a review of core literature on non-pharmacological interventions, the eRA SC determined that strong evidence exists to support use of physical activity, patient education and self-management, psychosocial interventions, and occupational therapy and orthotics. Evidence was lacking or conflicting for diet and nutrition, hand exercises, and balneotherapy/hydrotherapy. A set of educational slides was produced by the eRA SC to summarise the evidence (Fig. 1) and provide top-line guidance on use of interventions in practice that should engage relevant members of the multi-disciplinary team. These slides are available through eRA dissemination activities.Conclusion:The eRA programme content is now freely available to health care professionals in several countries on a web platform, supported by translations of the eRA tools. An additional slide set on non-pharmacological management serves to further increase the practical guidance of this programme’s educational offering.Acknowledgments:The eRA programme is funded by Sanofi Genzyme. Programme direction and content creation are driven by an independent Steering CommitteeDisclosure of Interests:Gerd Rüdiger Burmester Consultant of: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Speakers bureau: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Jose-Maria Alvaro-Gracia Grant/research support from: Abbvie, Elli-Lilly, MSD, Novartis, Pfizer, Consultant of: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Paid instructor for: Elli-Lilly, Pfizer, Roche, Speakers bureau: Abbvie, BMS, Janssen-Cilag, Elli-Lilly, Gedeon Richter, MSD, Novartis, Pfizer, Sanofi, Tigenix, Roche, UCB, Neil Betteridge Consultant of: Amgen, Eli Lilly and Company, Grunenthal, GSK, Sanofi Genzyme, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, Bernard Combe Grant/research support from: Novartis, Pfizer, Roche-Chugai, Consultant of: AbbVie; Gilead Sciences, Inc.; Janssen; Eli Lilly and Company; Pfizer; Roche-Chugai; Sanofi, Speakers bureau: Bristol-Myers Squibb; Gilead Sciences, Inc.; Eli Lilly and Company; Merck Sharp & Dohme; Pfizer; Roche-Chugai; UCB, Patrick Durez Speakers bureau: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Pfizer, Sanofi, Ricardo J. O. Ferreira Grant/research support from: Abbvie, Consultant of: Sanofi Genzyme, Amgen, MSD, Paid instructor for: UCB, Bruno Fautrel Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Consultant of: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Lilly, Janssen, Medac MSD France, Nordic Pharma, Novartis, Pfizer, Roche, Sanofi Aventis, SOBI and UCB, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi, Carlomaurizio Montecucco: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Andrea Rubbert-Roth Consultant of: Abbvie, BMS, Chugai, Pfizer, Roche, Janssen, Lilly, Sanofi, Amgen, Novartis, Tanja Stamm Grant/research support from: AbbVie, Roche, Consultant of: AbbVie, Sanofi Genzyme, Speakers bureau: AbbVie, Roche, Sanofi, Zoltán Szekanecz Grant/research support from: Pfizer, UCB, Consultant of: Sanofi, MSD, Abbvie, Pfizer, Roche, Novertis, Lilly, Gedeon Richter, Amgen, Peter C. Taylor Grant/research support from: Celgene, Eli Lilly and Company, Galapagos, and Gilead, Consultant of: AbbVie, Biogen, Eli Lilly and Company, Fresenius, Galapagos, Gilead, GlaxoSmithKline, Janssen, Nordic Pharma, Pfizer Roche, and UCB, Mart van de Laar Consultant of: Sanofi Genzyme, Speakers bureau: Sanofi Genzyme

Background:The OMERACT Ultrasound (US) in calcium pyrophosphate deposition disease (CPPD) sub-task force has been working on the use of US in CPPD since 2014 first creating definitions for CPPD identification and then assessing the reliability[1].Objectives:Objective of this study is to assess the diagnostic accuracy (truth) of US in CPPD.Methods:Consecutive patients waiting to undergo knee replacement surgery due to osteoarthritis were enrolled in 12 centres from 6 countries. Each patient underwent US examination of the knee, focusing on the menisci and the hyaline cartilage, the day prior to surgery, scoring each site for presence/absence of CPP as defined previously[1]. After surgery, the menisci and the condyles were retrieved and examined microscopically. Six samples were collected, both from the surface and from the internal part of menisci and cartilage trying to cover a large part of it. All slides were observed under transmitted light microscopy and by compensated polarised microscopy. A dichotomous score was given for the presence/absence of CPP. US and microscopic analysis were performed by different operators, blind to each other’s findings. Sensitivity and specificity of US were calculated using microscopic findings as the gold standard.Results:101 patients have been enrolled in the study. 33 patients have been excluded due to loss of anatomical pieces at surgery. The mean age of the remaining 68 pts was 71yo (±8), 44 women, 34 were affected by CPPD according to microscopy. Overall and per site diagnostic US accuracy results are presented in table 1Diagnostic accuracySensitivitySpecificityPositive Predictive valueNegative Predictive valueGlobal0.750.910.590.690.87Medial meniscus0.820.870.770.770.87Lateral meniscus0.750.830.680.680.83Medial cartilage0.860.790.920.880.85Lateral cartilage0.820.710.880.770.84Medial side (combined cartilage and meniscus)0.820.880.760.790.87Lateral side (combined cartilage and meniscus)0.780.880.690.730.86Conclusion:Our results demonstrate that US is an accurate exam for identification of CPPD. The best combination of sensitivity and specificity is achieved by examining the medial aspect of the knee.References:[1]Filippou G, Scirè CA, Adinolfi A,et al.Identification of calcium pyrophosphate deposition disease (CPPD) by ultrasound: reliability of the OMERACT definitions in an extended set of joints—an international multiobserver study by the OMERACT Calcium Pyrophosphate Deposition Disease Ultrasound Subtask Force.Ann Rheum Dis2018;:annrheumdis-2017-212542. doi:10.1136/annrheumdis-2017-212542Disclosure of Interests:Georgios Filippou: None declared, Anna Scanu: None declared, Antonella Adinolfi: None declared, Carmela Toscano: None declared, Dario Gambera: None declared, Raquel Largo: None declared, Esperanza Naredo: None declared, Emilio Calvo: None declared, Gabriel Herrero-Beaumont: None declared, Pascal Zufferey: None declared, Christel Madelaine-Bonjour: None declared, Daryl MacCarter: None declared, Stanley Makman: None declared, Zachary Weber: None declared, Fabiana Figus: None declared, Ingrid Möller: None declared, Marwin Gutierrez: None declared, Carlos Pineda: None declared, Denise Clavijo Cornejo: None declared, Héctor García: None declared, Victor Ilizaliturri: None declared, Jaime Mendoza Torres: None declared, Raul Pichardo: None declared, Luis Carlos Rodriguez Delgado: None declared, Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work., Edoardo Cipolletta: None declared, Teodora Serban: None declared, Catalin Cirstoiu: None declared, Florentin Ananu Vreju: None declared, Dun Grecu: None declared, Gael Mouterde: None declared, Marcello Govoni: None declared, Leonardo Punzi: None declared, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Lene Terslev Speakers bureau: LT declares speakers fees from Roche, MSD, BMS, Pfizer, AbbVie, Novartis, and Janssen., Carlo Alberto Scirè: None declared, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi

Background:Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children. Musculoskeletal ultrasound (MSUS) is a reliable tool in the assessment of chronic inflammatory arthropathies. MSUS in JIA has demonstrated a higher sensitivity for detecting synovitis and tenosynovitis as compared to physical examination. The occurrence of subclinical synovitis (Sub-S: MSUS+/ physical examination -) seems more frequent in wrist and foot joints; the clinical significance of Sub-S in real-life practice is still debated. Methotrexate (MTX) is the most widely used first-line DMARD in JIA therapy. Weekly treatment with MTX leads to clinical remission (CR) in 50-70% of patients. After a variable period of CR (usually 6-18 months), MTX is discontinued. Relapse rate after MTX suspension ranges between 40-50%; no predictors of disease flare have been identified so far.Objectives:We designed a cohort study in order to explore if MSUS monitoring during MTX tapering was able to predict disease flare.Methods:JIA patients in CR (as defined by the JADAS score) for at least 12 months were enrolled in the study. Patients at first attempt of suspension (G1) were tapered as follows: 1 week of suspension every 3 weeks for 3 months + 1 dose every 2 weeks for 3 months; if CR persisted, MTX was stopped. Patients who had a previous flare during/after MTX tapering (G2) had a similar tapering schedule but the step with 1 MTX dose every 2 weeks lasted 6 months. All patients underwent a complete MSUS of 48 joints every 3 months; clinicians who performed physical examinations and follow-up were blinded to US findings for the entire study period.Results:18 consecutive patients were enrolled between April 2018 and September 2019; patients had prevalently oligoJIA (55.5%) and RF- polyJIA (22.2%). Patients had been treated with MTX for 24.7 months (17.7–48.3), CR had been achieved 4.2 months after MTX start; 61.1% were at their first attempt of MTX tapering (G1).Baseline MSUS:at T0 MSUS detected 9/18 patients (50.0%) with Sub-S (MSUS+). Affected sites at T0 were distributed as follows: 4 MCP joints, 9 MTP joints, 1 f-IP joints, 11 knees. No significant differences resulted in comparing demographic and baseline disease features between MSUS- and MSUS+ patients at T0.Follow-up MSUS: 14 patients (77.8%) completed the entire study protocol, 4 patients are still ongoing. 7 patients relapsed: 42.9% during tapering, 1 of them relapsed during a VZV infection and was excluded from further analysis. We considered as Tlast-MSUS the last available MSUS before relapse or final MSUS (i.e. three months after MTX withdrawal) for not-relapsed subjects.At Tlast8 patients had at least 1 Sub-S. Sub-S per patient at Tlastwere more than Sub-S at T0 (2.85 vs 0.53 p=0.03) but the presence of Sub-S was not related with disease flare (50.0 vs 44.4% p=1). MSUS found 27 Sub-S of the small joints (sMSUS): 88.9% were in the feet, they had an OMERACT grading of 1. sMSUS+ patients were older (8.7 vs 3.9, p=0.002) therefore a weight-induced sub-S not related with JIA could be presumed.Kaplan-Meier curves were analyzed comparing MSUS results at T0 and Tlast, both considering all Sub-S and excluding small feet joints (pMSUS). The best performance was achieved with MSUS at Tlastand pMSUS (figure below, p=0.11).Conclusion:•Sub-S are present in 50% of patients in clinical remission >12 months.•Sub-S in older patients interest often feet small joints; these Sub-S may be of mechanical origin and are not associated with disease flare.•Sub-S increase during MTX tapering.Further patients must be enrolled to understand if Sub-S excluding feet small joints may predict disease flare.References:[1]Amendment of the OMERACT US definitions of joints’ features in healthy children using the DOPPLER technique. Collado P et al, Pediatr Rheumatol Online J. 2018.[2]Preliminary Definitions for the Sonographic Features of Synovitis in Children. Roth J, et al; Arthritis Care Res. 2017.Disclosure of Interests:Francesco Licciardi: None declared, Marta Dellepiane: None declared, Carlotta Covizzi: None declared, Fabiana Figus: None declared, Irene Azzolin: None declared, Davide Montin Speakers bureau: Not relevant for the topic, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi

The absence of specific guidance on how to use ultrasound (US) to diagnose and manage patients with inflammatory arthritis, especially with rheumatoid arthritis (RA) has hindered the optimal utilisation of US in clinical practice, potentially limiting its benefits for patient outcomes. In view of this, a group of musculoskeletal US experts formed a working group to consider how this unmet need could be satisfied and to produce guidance (additional to European League against Rheumatism (EULAR) imaging recommendations) to support clinicians in their daily clinical work. This paper describes this process and its outcome, namely five novel algorithms, which identify when US could be used. They are designed to aid diagnosis, to inform assessment of treatment response/disease monitoring and to evaluate stable disease state or remission in patients with suspected or established RA, by providing a pragmatic template for using US at certain time points of the RA management. A research agenda has also been defined for answering unmet clinical needs.

For patients with rheumatoid arthritis (RA), remission can be achieved with tight control of inflammation and early use of disease modifying agents. The importance of remission as an outcome has been recently highlighted by European League Against Rheumatism recommendations. However, remission when defined by clinical remission criteria (disease activity score, simplified disease activity index, etc) does not always equate to the complete absence of inflammation as measured by new sensitive imaging techniques such as ultrasound (US) . There is evidence that imaging synovitis is frequently found in these patients and associated with adverse clinical and functional outcomes. This article reviews the data regarding remission, ultrasound imaging and outcomes in patients with RA to provide the background to a consensus statement from an international collaboration of ultrasonographers and rheumatologists who have recently formed a research network - the Targeted Ultrasound Initiative (TUI) group. The statement proposes that targeting therapy to PD activity provides superior outcomes compared with treating to clinical targets alone and introduces the rationale for a new randomised trial using targeted ultrasound in RA.

Some experiences with intra-articular (IA) infliximab treatment in patients with refractory monoarthritis have been reported, even though these studies have important limitations including small sample size and short trial duration.1–4 Aim of this study was to evaluate the efficacy and safety of IA infliximab administration in a larger cohort of patients. We studied 10 patients with rheumatoid arthritis (RA) and seven with psoriatic arthritis (PsA) with active monoarthritis lasting at least 3 months, refractory to disease-modifying antirheumatic drugs (DMARDs) and to IA glucocorticoids.5 6 DMARDs dose had to be stable for at least 6 weeks before IA injection of infliximab, …

Objective: To propose e-learning methods that address the fundamental problems related to sonographic training in rheumatology. Methods: The project was designed for rheumatologists with strong motivation to learn ultrasound. A modular approach was constructed, consisting of a basic 3-day residential course, followed by a 6-month period of web-based tutoring, and culminating in a final 2-day residential course with a formal assessment of competency. Results: The website (http://www.e-sonography.com) was accessed by all 60 participants. A mean of 20 (range 10–80) log-on sessions were registered for each participant, and a mean of 250 min (range 60–600 min) of web access was recorded. A total of 163 sonographic images were submitted by 18 (30%) participants. The majority of the images focused on the following anatomical areas: shoulder 49 (30%), hand 34 (21%) and knee 20 (12%). A total time investment of approximately 14 h was made by the US tutors over the 6-month period for interaction with the participants. Conclusions: The e-learning methods described in this report represent the first attempt to adopt a novel technique to circumvent several of the inherent barriers to the many facets of teaching musculoskeletal ultrasound to a wide audience.

To use power Doppler sonography (PDS) to evaluate changes in synovial perfusion induced by adalimumab in the wrist joints of patients with rheumatoid arthritis.48 wrists of 24 patients (18 women and 6 men) were examined. Despite prior treatment with disease-modifying antirheumatic drugs, including methotrexate, patients with clinically active rheumatoid arthritis were recruited in two rheumatological centres to receive 40 mg adalimumab subcutaneously every other week. Clinical, laboratory and PDS assessments were carried out at 0, 2, 6 and 12 weeks. Clinical and laboratory measurements of disease activity included physician's global assessment of disease activity, erythrocyte sedimentation rate and serum levels of C reactive protein. The Disease Activity Score for 28 joints (DAS28) was calculated. PDS signal was scored from 0 to 3 according to the overall expression of PDS findings at the wrists.A significant reduction in both clinical (p0.001) and PDS findings (p0.001) was found at all follow-up examinations. A tendency to positive correlation (Spearman's r = 0.382; p = 0.067) was shown between reduction in PDS score and improvement in DAS28 at week 2 examination.PDS detected a rapid and significant reduction in synovial perfusion at the wrist joints of patients with rheumatoid arthritis receiving adalimumab. Ongoing follow-up will provide further information regarding the persistence of considerable reduction in PDS signal score and its correlation with DAS28.

Objective: To assess the intra-reader and inter-reader reliabilities of interpreting ultrasonography by several experts using video clips. Method: 99 video clips of healthy and rheumatic joints were recorded and delivered to 17 physician sonographers in two rounds. The intra-reader and inter-reader reliabilities of interpreting the ultrasound results were calculated using a dichotomous system (normal/abnormal) and a graded semiquantitative scoring system. Results: The video reading method worked well. 70% of the readers could classify at least 70% of the cases correctly as normal or abnormal. The distribution of readers answering correctly was wide. The most difficult joints to assess were the elbow, wrist, metacarpophalangeal (MCP) and knee joints. The intra-reader and inter-reader agreements on interpreting dynamic ultrasound images as normal or abnormal, as well as detecting and scoring a Doppler signal were moderate to good (κ = 0.52–0.82). Conclusions: Dynamic image assessment (video clips) can be used as an alternative method in ultrasonography reliability studies. The intra-reader and inter-reader reliabilities of ultrasonography in dynamic image reading are acceptable, but more definitions and training are needed to improve sonographic reproducibility.

In the last few years the application of musculoskeletal imaging in rheumatology clinical practicehas become more widespread. However recommendations on its use in osteoarthritis (OA) are lacking. Objective To develop evidence-based recommendations for the use of imaging in OA clinical practice Methods After the project was approved by the EULAR Executive Committee, a task force of experts in the field of OA and imaging met in order to plan the strategy for a systematic literature review (SLR), subsequently conducted by a research fellow under the supervision of the conveners and the methodologist of the group. The task force identified areas of application of imaging in OA clinical practice and developed the research questions to drive the SLR. The imaging modalities (conventional radiography, ultrasound, magnetic resonance imaging, computed tomography, radioisotope scan) and joints (knee, hip, hand and foot) were first identified. Second, the role of imaging in the diagnosis of OA, identification of OA characteristics, detection of other diseases, managing OA, defining its prognosis, monitoring the disease progression as well asguiding treatment was addressed. A systematic search was performed separately for each question and site using PubMed and Embase. Results From an initial SLR, 6858 references were found, 1317 papers were reviewed in detail and 380 of them were included. Furthermore, to investigate evidence not addressed by the first SLR,the task force required additional SLRs to evaluate the accuracy and efficacy of imaging-guided compared to blind injections and the comparison of different radiographic projections. For the first SLR, 25 papers out of 5379 abstracts were assessed and 8 included, while for the comparison of different projections 53 papers out of 4774 abstracts were reviewed, with the inclusion of 31 papers. After analysing the results of the SLRs and giving their expert opinion, the task force developed consensus recommendations. These covered different areas such as the lack of need for diagnostic imaging in patients with typical symptoms, the role of imaging in differential diagnosis, the use of imaging in monitoring OA when no significant therapeutic modification isrelated, the first choice imaging modality, how to acquire images, the influence of different joints on selecting the type and use of imaging modalities, and the role of imaging in guiding local injections. Future research recommendations were developed based on areas where there was a paucity of literature. Conclusions EULAR recommendations for the use of imaging in osteoarthritis clinical practice have been developed thus filling a knowledge gap in the field. Key messages –Recommendations on the use of imaging in OA clinical practice are lacking. –Based on the results of a SLR and expert opinion, recommendations on the use of imaging in the clinical management of OA were developed. Disclosure of Interest None declared

By 2017, EULAR will be a pre-eminent provider and facilitator of high-quality education for physicians, health professionals in rheumatology, and people with rheumatic and musculoskeletal diseases. In addition to educational sessions at the annual congress and the EULAR symposia at AFLAR, PANLAR, APLAR, currently available educational offers cover different fields and are represented by online and live courses, exchange programmes, bursaries, grantsand awards, publications and other materials. In terms of online courses, in recent years, EULAR has put substantial effort and investment into developing e-learning opportunities. All EULAR courses, as electronic ways of continuous medical education in rheumatology, are managed by a scientific course committee responsible for the structure and content of the courses and for ensuring quality control. EULAR teams of expert authors regularly review and update courses to keep up with the newest developments in the field. While the 2-year Online Course on Rheumatic Diseases offers a comprehensive introduction to and update on all aspects of rheumatology, a number of shorter online courses (i.e. US introductory, Paediatric, Health Professionals, Systemic Sclerosis) offer flexible learning for the specialist. Live courses are currently planned and developed with the objective of making a targeted contribution to training and further education to rheumatologists and health professionals, complementing the standard range of opportunities provided by universities, hospitals and other institutions. To this end EULAR offers a number of its own branded courses and, in addition, grants “EULAR scientific endorsement” as a mark of scientific quality to selected courses and meetings run by established providers in Europe. In this context, EULAR invites other courses and scientific meetings in the field of rheumatology to apply for endorsement. EULAR views scientific endorsement as an opportunity to positively influence the quality of rheumatology training in Europe, which is in line with EULAR longer-term goals. Quality control associated with EULAR scientific endorsement focuses on the proposed content and faculty as well as on evaluation of these courses or meetings. The purpose of the EULAR/ACR Exchange Program is to promote the international exchange of clinical and research skills, expertise and knowledge within rheumatology. The program recognizes outstanding rheumatology faculty and provides exposure to the exciting work being done by colleagues overseas. This exchange program allows participants to share knowledge and experience, and creates opportunities for collaboration. Another EULAR objective is the use of bursaries to contribute to the personal and professional development of rheumatologists, health professionals as well as people with rheumatic diseases. To this end, EULAR facilitates attendance at the annual EULAR congress in the form of travel bursaries, also provides bursaries to attend EULAR courses in rheumatology. EULAR is committed to helping individuals develop their skills, expertise and network of contacts and therefore offers a range of educational grants tailored to the needs of researchers and clinicians, health professionals and patient organisations. Educational grants are offered at regular intervals. In terms of publications, in addition to the two EULAR journals (ARD and RMDopen), and next to the EULAR Textbook on Rheumatic Diseases, EULAR has published the Textbook on Systemic Sclerosis, and also endorsed several books which are relevant to the EULAR live and online courses. The new EULAR Texbook on Ultrasound will be launched at the annual Congress in London, on June 2016. Additional opportunities are represented by educational activities such as a network of imaging centres, videos which offer an insight into some EULAR courses and international events, practical DVDs with video production on undergraduate training in history and physical examination of the musculoskeletal system. New activities that will be launched in 2016 are a medical student primer, student webinars on “case of the month” and webinar monthly lecture given by experts. Key messages –By 2017, EULAR will be a pre-eminent provider and facilitator of high-quality education for physicians, health professionals in rheumatology, and people with rheumatic and musculoskeletal diseases. –Currently available educational offers cover different fields with online and live courses, exchange programmes, bursaries, grants and awards, publications and other materials. Disclosure of Interest None declared

The use of musculoskeletal ultrasound in rheumatology clinical practice has become widespread with increasing demand from rheumatologists attending EULAR Sonography Courses and participating in educational activities in the field. However, musculoskeletal ultrasound is widely considered an operator dependent imaging technique for which high level training and appropriate competency assessment are crucial in order to ensure the quality of ultrasound examinations. EULAR offers a huge educational programme in musculoskeletal ultrasound, with a number of own branded multi-level live sonography courses and an online introductory course on ultrasound, of which high quality structure and content is ensured. In addition, EULAR grants “scientific endorsement” as a mark of scientific quality to selected courses organised by established experts. Moreover, EULAR guidelines and recommendations on how to perform musculoskeletal ultrasound in rheumatology, and for the content and conduct of ultrasound, including teach-the-teachers, courses have recently been published, thus filling a knowledge gap in the field. There was however, still the need for assessing the level of competency of delegates attending these educational courses in order to improve and regulate the skills of rheumatologists performing ultrasound. As a result, the EULAR competency assessment in musculoskeletal ultrasound in rheumatology was launched in 2015 with this objective. This new system represents an example of certification offered by EULAR and is based on 2 levels of competency: 1) Level 1 (i.e. the minimum level required to independently perform full rheumatologic musculoskeletal ultrasound, the contents of which are included in the EULAR online, basic, intermediate and advanced courses). 2) Level 2 (i.e. the minimum level required to teach musculoskeletal ultrasound). The EULAR faculty, a group of highly qualified and experienced experts in the field, assess the attendees of the annual EULAR sonography and teach-the teachers courses in order to provide EULAR certification approving their level of competency. All these procedures are regulated by rules available on the EULAR web site (www.eular.org). The competency assessment requirements are reported below: Level 1 –To complete the EULAR online MSUS course successfully. –To attend the Basic and Intermediate EULAR MSUS course, or equivalent EULAR scientifically endorsed MSUS course and the Advanced EULAR MSUS course with a maximum of 2 years in between each course. –To perform and document a minimum of 10 standardized complete MSUS examinations of each joint region (i.e. shoulder, elbow, wristh published online May 21, 2013; www.efsumb.org/guidelines) –To successfully pass a practical exam that takes place during the Advanced EULAR MSUS course. Level 2 –To have achieved level 1 competency. –To attend the annual EULAR MSUS Teach the Teacher course and successfully pass the theoretical and practical examination on MSUS teaching capability that takes place during said course. –The level 2 competency certification can be delivered under particular circumstances (and after having verified the particular requirements, by the EULAR Faculty members) to MSUS experts who have been a teacher in a EULAR MSUS Teach the Teacher course within the previous 3 years or have been a teacher in three Intermediate/Advanced EULAR MSUS courses within the previous 5 years. Key messages: –Appropriate training and competency assessment are highly important to ensure an appropriate and skilled use of musculoskeletal ultrasound by rheumatologists –The EULAR competency assessment in musculoskeletal ultrasound represents a unique opportunity to guarantee a high level of competency of rheumatologist ultrasonographers Disclosure of Interest None declared

Objectives To produce ultrasound (US) consensus-based definitions of cartilage change in rheumatoid arthritis (RA) and assess its intraobserver and interobserver reliability in a web-based exercise. Methods We conducted a Delphi study on US defined cartilage change and a proposed semiquantitative (SQ) US scoring system for cartilage change in RA. A written Delphi questionnaire was developed based on a systematic literature review and expert international consensus and was distributed via consecutive written questionnaires by email to a group 35 rheumatologists from 17 countries with experience in musculoskeletal US. Taskforce members performed US B mode examination of the metacarpal cartilage in metacarpophalangeal joints 2–5 in RA patients and the images were collected in an electronic database. A reference image atlas of cartilage changes was developed for scoring 123 anonymized images including 25 duplicate images. These were sent to the participants who independently scored the images. Intraobserver reliability was assessed by Cohen9s kappa and interobserver reliability by Fleiss9 kappa. Results Group agreement (76–100%) was reached for 6 statements concerning: i) MSUS definition and assessment of normal hyaline cartilage, ii) elementary cartilage lesions in MSUS and iii) grading of elementary cartilage lesions in patients with RA in a two-round Delphi consensus process. A three-grade SQ (0–2) scoring system (grade 0, normal cartilage; grade 1, minimal change: blurring of outer and/or subchondral margin, focal thinning or incomplete loss of homogeneity of echostructure; grade 2, severe: diffuse thinning or complete loss of homogeneity of echostructure) was agreed for scoring cartilage damage in RA. Both intra- and inter-observer reliability were good (κ value of 0.87 and 0.64 respectively). Conclusions This study demonstrates that US is a reliable tool for evaluating cartilage in RA and strongly supports the use of a new reliable semiquantitative MSUS scoring system for cartilage change. Disclosure of Interest None declared

Background Ultrasound (US) is increasingly used for the diagnosis of large vessel vasculitis (LVV), as this imaging technique enables the visualization of the inflammatory vessel wall swelling. A consensus about the definition of US lesions for diagnosis of LVV has not yet been accomplished. Objectives 1) To identify definitions of US lesions in LVV; 2) to evaluate the role of US in monitoring disease response; and 3) to assess the value of identified US lesions for diagnosis of LVV. Methods A systematic literature search was conducted in PubMed, Embase and the Cochrane Library (till 23rd November 2014). Research articles enrolling at least 20 patients with suspected cranial giant cell arteritis (GCA) or large-vessel GCA (LV-GCA), Takayasu arteritis (TAK), published in English or German were selected. The study design, subjects, methods, imaging protocols and diagnostic values were evaluated, as well as the US definitions of vasculitis. The quality of the included studies was assessed by the QUADAS2 tool. Results Of 2960 articles identified, 34 studies were included in the review for the extraction of definitions of vasculitis in US. Thirty-two reports addressed the role of US in diagnosis of cranial GCA, whereas only 6 studies evaluated US in the settings of LV-GCA. The role of US in disease monitoring was evaluated in 11 articles on cranial GCA and in 2 articles on LV-GCA. No studies assessing the role of US in TAK fulfilled the inclusion criteria. Most studies investigated the value of the “halo sign” (32 articles), whereas “compression sign”, “stenosis”, “occlusion” or “decreased vessel wall pulsation” as signs of vasculitis were addressed in 1, 22, 19, and 1 paper(s), respectively. Conclusions US is a valuable diagnostic tool in patients with suspected GCA. In this systematic literature review we identified “halo sign”, “stenosis”, “occlusion”, “compression sign” and a “decreased vessel wall pulsation” as possible key US lesions for vasculitis. Based on these results future research on the role of US in LVV is now being performed by the OMERACT US group. Disclosure of Interest None declared

Background Musculoskeletal ultrasound (MSUS) has evolved into an important method for identifying musculoskeletal abnormalities, confirming the diagnosis in patients with suspected inflammatory arthritis, monitoring therapeutic response, influencing clinical decision making and guiding interventions. The role of the non-medical health professional has advanced with many health professionals undertaking training and using MSUS to extend their scope of practice. Guidelines to support training for rheumatologists have been identified but currently there are not any recommendations to support the education and training needs of non-medical health professionals using MSUS. Objectives The EULAR Task Force was established to reach a consensus on the role and education and training needs of non-medical health professionals undertaking MSUS for the management of patients with rheumatic and musculoskeletal diseases (RMDs). Methods The EULAR Task Force comprised an expert group from 11 European countries. The Task Force met twice and included rheumatologists, nurses, physiotherapists, a radiologist, radiographer and podiatrist with patient representation. In the first meeting the aims of the Task Force were defined and fourteen research questions were developed. This was followed by a comprehensive systematic search of the literature to identify publications on the role of health professionals using MSUS, their competency requirements and training undertaken. During the second meeting the Task Force were presented with the results of the literature review which supported the formulation and consensus of “points to consider”. The level of agreement between task force members for each “point to consider” was determined after the second meeting. Results In total, seven “points to consider” were formulated. Two points covered the role and scope of health professionals using musculoskeletal ultrasound and one point addressed the application and feasibility in daily practice. Three “points to consider” focused on the training and competency required by health professionals and the final point addressed the added value in daily practice. The strength of the “points to consider” was D based on the category of evidence (3–4). A high level of agreement (range 9.0–9.7) was achieved between Task Force members. Additionally, the Task Force agreed upon eight topics for the future research agenda. Conclusions Seven “points to consider” for health professionals using MSUS for the management of patients with RMDs were developed using a combination of research-based evidence and expert consensus approach. Disclosure of Interest None declared

Background The increased availability of modern imaging in clinical practice has led to its more extensive use. In the field of osteoarthritis (OA), recommendations on the use of imaging in clinical trials have been developed, but there has been less focus on routine clinical management. Objectives To develop evidence-based recommendations for the use of imaging in the clinical management of OA. Methods A task force convened by the European League Against Rheumatism including rheumatologists, radiologists, generalists, methodologists and patients from 9 countries developed recommendations based on both evidence obtained through systematic literature review (SLR) and expert opinion. The task force initially identified the areas of application of imaging in OA and developed research questions to drive the SLR. Imaging modalities included were conventional radiography, ultrasound, magnetic resonance imaging, computed tomography, radioisotope scan. Anatomical areas of interest were knee, hip, hand and foot. Based on the priorities identified by the task force, the role of imaging in making a diagnosis of OA and identifying OA features (including soft tissue, bone and cartilage involvement), in detecting alternative diagnoses, the impact of imaging on disease management, in defining prognosis (natural history of the disease and response to treatment), in the follow up of the disease and to guide treatment were addressed. Research evidence was searched systematically for each question and separately for each anatomic area using PubMed and Embase. Results The systematic review retrieved 6858 references, after the assessment of 1317 full papers, 380 studies were included. The results of the systematic review were presented to the task force, and consensus recommendations derived. These cover areas such as (exact wording not included for brevity reasons): the lack of need for imaging in diagnosis of patients who present with usual OA symptoms; role of imaging in differential diagnosis; consideration of the challenges in using imaging for routine monitoring of OA where there is no change in clinical status; what should be the feasible first choice modality and what issues were relevant to how images were acquired; how anatomical site of OA may influence use and type of imaging; and the role of imaging and intra-articular injection. Significant gaps in the literature underpinned the recommendations for future research that were also developed. Conclusions Based on the results of a SLR and expert opinion, recommendations on the use of imaging in the clinical management of OA were developed. Disclosure of Interest None declared

The objective of this study was to develop European League Against Rheumatism/American College of Rheumatology classification criteria for polymyalgia rheumatica (PMR). Candidate criteria were evaluated in a 6-month prospective cohort study of 125 patients with new-onset PMR and 169 non-PMR comparison subjects with conditions mimicking PMR. A scoring algorithm was developed based on morning stiffness > 45 minutes (2 points), hip pain/limited range of motion (1 point), absence of rheumatoid factor and/or anti-citrullinated protein antibody (2 points), and absence of peripheral joint pain (1 point). A score >= 4 had 68% sensitivity and 78% specificity for discriminating all comparison subjects from PMR. The specificity was higher (88%) for discriminating shoulder conditions from PMR and lower (65%) for discriminating RA from PMR. Adding ultrasound, a score >= 5 had increased sensitivity to 66% and specificity to 81%. According to these provisional classification criteria, patients >= 50 years old presenting with bilateral shoulder pain, not better explained by an alternative pathology, can be classified as having PMR in the presence of morning stiffness > 45 minutes, elevated C-reactive protein and/or erythrocyte sedimentation rate, and new hip pain. These criteria are not meant for diagnostic purposes.

Background Power Doppler (PD) ultrasonography (US) is playing an increasing role in the evaluation of patients with inflammatory arthropathies, due to its ability in detecting inflammatory and structural abnormalities and the higher sensitivity compared with clinical evaluation. Several studies evaluated the role of US in diagnosis and follow-up of Rheumatoid Arthritis (RA) patients. A growing number of papers investigated the potential of US in the assessment of psoriatic arthritis (PsA). Indirect data suggested similar US findings in RA and PsA patients. However, to our knowledge, no study specifically designed to compare PDUS findings in RA and PsA patients has been performed. Objectives We assessed the ultrasonographic changes in terms of prevalence and severity of synovitis in clinically active RA and PsA patients. Methods In this cross-sectional study, we enrolled patients affected by RA and PsA with active peripheral joint involvement. The patients underwent clinical, laboratory and US evaluation. Disease activity was evaluated by the 28-joint DAS. We excluded all the patients in remission (i.e. DAS28 Results We enrolled 43 PsA (M/F 20/23; mean age 54.8±15.2 years; mean disease duration 112.6±70.8 months) and 70 RA patients (M/F 11/59; mean age 56.4±14.8 years; mean disease duration 158.7±40.4 months). DAS28 values resulted significantly higher in RA compared with PsA (5.3±1.1 versus 4.3±1.1, P=0.0001). US evaluation demonstrated a significantly higher prevalence of all US-detected lesion in RA patients compared with PsA (JE 60.9% versus 41.1%, P versus 31.3%, P versus 11.6%, P versus 1.5±2.1, P=0.03) and moderate disease activity (12.6±9.2 versus 7.4±6.7, P=0.01). Conclusions The present study demonstrate that PDUS synovitis is more severe in RA than in PsA patients, regardless of the disease activity. Concerning the prevalence of each US-detected abnormality, JE, SH and PD signal resulted significantly more frequent in RA patients than PsA. References Perricone C et al. The 6-joint ultrasonographic assessment: a valid, sensitive-to-change and feasible method for evaluating joint inflammation in RA. Rheumatology (Oxford) 2012;51:866-73. Disclosure of Interest None declared

Background In the complex pathogenesis of Systemic Lupus Erythematosus (SLE), both genetic and environmental factors are involved possibly influencing the disease phenotype. Articular involvement is a frequent manifestation whose features range from arthralgia to erosive arthritis. Musculo-skeletal ultrasonography (MSUS) has proven useful in the assessment of inflammatory arthropathies and is more sensitive than radiography in detecting bone erosions. Objectives We aimed at analyzing, in a population of Italian SLE patients, the relationship between 25 polymorphisms in 16 genes previously associated with SLE or other autoimmune diseases [1] and the presence of bone erosions observed by MSUS. Methods Fifty-six consecutive SLE patients (M:F 3:53; mean age 41.5±10.0 years; mean disease duration 12.7±10.3 months) were enrolled. SLE diagnosis was performed according to the 1997 revised ACR criteria. Study protocol included complete physical examination and clinical and laboratory data collection. Twenty-five polymorphisms in 16 genes (STAT4, IL10, IL23R, IRAK1, PSORS1C1, HCP5, MIR146a, PTPN2, ERAP1, ATG16L1, IRGM, TRAF3IP2, VKORC1, CCR5, ATG5) were genotyped by allelic discrimination assays. Finally, bilateral high-resolution MSUS of the hand and foot joints was performed. The presence of erosive damage was assessed with a dichotomous score (absence/presence). Results Forty-nine over 56 (87.5%) patients suffered from joint involvement in their clinical history. This clinical feature was associated with the presence of anti-Sm (P Conclusions Joint involvement, defined as per the 1997 revised ACR criteria, is a frequent manifestation in patients affected with SLE. However, the presence of bone erosions is far less common, may require a different management and may have a distinct pathogenesis. ATG5 is a possible candidate gene associated with disease susceptibility, and a key player in autophagy whose perturbations have been related with the development of SLE. Nonetheless, increased autophagy is an adaptive response to protect cells from stresses, and autophagy may regulate osteoarthritis-like gene expression changes, possibly protecting from the development of erosive damage. Since the clinical role of ATG5 in SLE may depend on other gene variants [2], its dichotomous behavior may not be surprising and deserves further investigation. References Ciccacci C, Perricone C, Ceccarelli F, Rufini S, Di Fusco D, Alessandri C, Spinelli FR, Cipriano E, Novelli G, Valesini G, Borgiani P, Conti F. A multilocus genetic study in a cohort of Italian SLE patients confirms the association with STAT4 gene and describes a new association with HCP5 gene. PLoS One. 2014;9:e111991. Lόpez P, Alonso-Perez E, Rodriguez-Carrio J, Suarez A. Influence of Atg5 mutation in SLE depends on functional IL-10 genotype. PLoS One. 2013;8:e78756. Disclosure of Interest None declared

Background Joint involvement occurs in up to the 90% of patients with Systemic Lupus Erythematosus (SLE), with a wide spectrum of clinical features. Musculo-skeletal ultrasonography (US) has been successfully used in the assessment of inflammatory arthropathies. In particular, the presence of power Doppler (PD) signal, able to detect active inflammation through the identification of pathologically blood perfusion, has been considered a risk factor for the development of erosive damage in patients with Rheumatoid Arthritis (RA). Few studies focused on the evaluation of joint involvement in SLE by PDUS. This imaging technique confirmed its higher sensitivity compared with clinical evaluation. However, to our knowledge, the role of PDUS in SLE patients is still poorly investigated. Objectives To evaluate the presence of PDUS synovitis and its associations with US-detected erosive damage at the level of hand and foot joints in SLE patients. Methods One hundred and two consecutive SLE patients (M/F 1/101; mean age 44.5±11.6 years; mean disease duration 144.6±103.2 months) complaining joint involvement were enrolled. All patients underwent clinical evaluation, laboratory tests and bilateral high-resolution US of the metacarpophalangeal, (MCP), proximal interphalangeal (PIP), and metatarsophalangeal (MTP) joints. Joint effusion (JE), synovial hypertrophy (SH), PD and erosive damage were assessed with a dichotomous score (absence or presence) and then graded according to a semi-quantitative scale ranging from 0 to 3 (0=absent, 1=mild, 2=moderate and 3=severe). US inflammatory scores, calculated by adding the values given to each elementary lesion, were elaborated at the level of all single joints and at all joint groups (MTPs, MCPs, PIPs). Finally, a global score was obtained by adding the scores of all joint groups. Results PDUS evaluation identified a median global US score of 16 (range 0-148). The median MCP, PIP and MTP joints scores were 2 (range 0-50), 1 (range 0-38) and 4 (range 0-38), respectively. The PIP score was significantly lower compared to MCP (P versus median 0, range 0-7, P Conclusions In the present study, we identified an association between PD and erosive damage in SLE patients with symptomatic joint involvement. Those results, similarly to previously reported data on RA, suggest a role of PD as a prognostic factor for aggressive and severe arthritis, which may be able to guide the physician in therapeutic options. Disclosure of Interest None declared

Background Ultrasonography (US) is an imaging tool able to evaluate patients affected by inflammatory arthropathies, thanks to its ability in detecting inflammatory and structural abnormalities and to its higher sensitivity compared with clinical evaluation. Several studies evaluated the role of US in diagnosis and follow-up of patients with Rheumatoid Arthritis (RA), mainly focusing on joint synovitis. Few studies evaluated specifically the inflammatory tendon involvement. Objectives We aimed to evaluate the prevalence and clinical significance of tenosynovitis detected by US in patients with RA with moderate/high disease activity naive to biological treatment. Methods In this cross-sectional study, we enrolled patients affected by RA (1987 ACR criteria) candidate to start biological treatment. The patients underwent clinical, laboratory and ultrasonographic evaluation. Disease activity was evaluated using 28-joint DAS. Health assessment questionnaire (HAQ) was also administered. Bilateral high-resolution US at the level of flexor tendons of II and III finger and extensor tendon compartments at wrist level was performed. Moreover, II metacarpophalangeal (MCP), III MCP and radiocarpal (RC) joints were evaluated. Tenosynovitis, joint effusion (JE), synovial hypertrophy (SH) and PD were evaluated according to OMERACT definitions. All the lesions were graded according to a semi-quantitative scale ranging from 0 to 3 (0=absent, 1=mild, 2=moderate and 3=severe). Then, US inflammatory scores, calculated by adding the values given to each elementary lesion, were elaborated for every single joint or tendon. Finally, a global score was obtained by adding together the scores from each joint and tendon separately. Moreover, PD both at joint and tendon levels was evaluated also by using a dichotomous score (presence/absence). Results Forty-eight patients affected by RA were evaluated. In table the main clinical, laboratory and ultrasonographic features are summarized. Tenosynovitis was observed in 30/48 (62.5%) patients. Synovitis and erosions were identified in all patients. The presence of tenosynovitis was associated with high disease activity (defined as DAS28>5.1, P=0.015), with the positivity for rheumatoid factor (P=0.025) and with the presence of anti-CCP (P=0.023). Moreover, a positive correlation between the synovitis score and, respectively, the erosion score (P Conclusions We demonstrated that US-detected tenosynovitis is a relevant manifestation in RA patients. Indeed, it is associated with serologically positive patients and with higher disease activity. PD was confirmed to correlate with a more severe bone damage in terms of erosions observed by US. Disclosure of Interest None declared

Painful shoulder is a very common condition in clinical rheumatology. However, knowledge of the lesions responsible for shoulder pain in most patients has been limited to clinical examination and plain radiography in clinical practice. High frequency ultrasonography is an accurate,1–4 non-invasive, and cheap imaging technique available in clinical rheumatology for evaluating patients with painful shoulder. However, dependence on the skill of the operator has been considered to be the main disadvantage of ultrasound. Diagnostic results are affected by the quality of the equipment, …

Background Joint synovial inflammation is the primary abnormality in rheumatoid arthritis (RA) and monitoring of the response of synovitis to treatments has a fundamental importance in the management of RA patients. Power Doppler ultrasound (PDUS) has been demonstrated to be valid, reliable and sensitive-to-change in RA. However, its routine use in daily rheumatologic practice is often considered time-consuming, particularly in the assessment of the characteristic poly-articular involvement of the disease (1). Objectives To monitor by PDUS the short term response to anti-TNFα therapy in 6 “target joints” of RA patients and to correlate PDUS findings with clinical and laboratory indexes of disease activity. Methods Consecutive RA patients starting anti-TNFα therapy were included and studied at baseline and after 3 months of treatment. All patients were evaluated by PDUS at the level of 6 “target joints” (II MCP, wrist and knee bilaterally). The components of synovitis (synovial hypertrophy, joint effusion, PD signal) were analyzed and graded according to a 0-3 semi-quantitative score. In addition, by differently summing the PDUS findings, 3 different scores were calculated: a joint score (0-18; at II MCP, wrist and kneejoints), a single inflammatory lesion score (0-18; synovial hypertrophy, joint effusion, PD signal) and a global score at patient level (0-54; sum of all abnormalities). Finally, clinical (N° tender joints; N° swollen joints; VAS;DAS28) and laboratory (ESR; CRP) assessments were conducted. Wilcoxon and Spearman9s tests were used for statistical analysis. Results 68 RA patients (M/F 11/57; mean age 53.0±15.2 years, mean disease duration 143,6±41.0 months) treated with anti-TNFα therapy (45 etanercept, 23 adalimumab; 52 in combination with DMARDs) were included. A significant decrease of the joint score in all articular sites (MCP P=0.003; knee P=0.002; wrist P=0.0001) as well as of the scores of the single components of synovitis (P=0.0001-0.002) and of the global 6-joint score (P=0.0001) was found. In addition, all clinical and laboratory parameters were significantly decreased at follow-up (P=0.0001-0.001). Finally, a significant positive correlation was observed between the global PDUS score and DAS28 (r=0.38; P=0.001). Conclusions PDUS is a sensitive-to-change imaging modality for the monitoring of short-term response to anti-TNFα treatment in RA patients. The assessment of the response to treatment in a limited number of joints makes the evaluation feasible in the daily rheumatologic practice as a complimentary tool to clinical assessment. References Perricone C, Ceccarelli F, Modesti M, Vavala C, Di Franco M, Valesini G, Iagnocco A. The 6-joint ultrasonographic assessment: a valid, sensitive-to-change and feasible method for evaluating joint inflammation in RA.Rheumatology (Oxford). 2012;51:866-73. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3352

EULAR has always had a strong commitment in teaching ultrasound in rheumatology. Over time EULAR has developed a broad educational offering in the field which today includes ultrasound courses, both physical and electronic, a textbook as well as practical skills sessions at EULAR Congress. This contribution complements the standard range of opportunities to teach ultrasound provided by universities, hospitals and other institutions. EULAR Ultrasound Course – The course takes place annually prior to the annual EULAR congress, in the same city. The aim of this three level course (basic, intermediate, advanced) is to cover the whole spectrum of conditions in which ultrasound could be used in rheumatology practice. The EULAR sonography course consists of a combination of lectures and hands-on-scanning of healthy individuals and patients with different rheumatic diseases, in small groups with experienced tutors. The basic level course aims at teaching sonoanatomy, standardised ultrasound scanning methods according to EULAR guidelines and basic ultrasound pathology as well as giving an overview of the role of ultrasound in rheumatologic clinical practice [1]. The intermediate level course aims at consolidating standardized scanning methods, as well as assessing pathology by ultrasound and knowing its role in different musculoskeletal pathologies. The advanced course focuses on difficult issues within ultrasound and includes time for discussion with expert rheumatologists and radiologists in the field. EULAR Ultrasound Trainer Course – The course takes place prior to the EULAR Ultrasound Course and the annual EULAR Congress. The course is mainly addressing rheumatologists who are planning to organize an EULAR Endorsed Ultrasound Course and aims at improving teaching skills for both lectures and hands-on ultrasound workshops. Participants also learn how to organize an ultrasound course and evaluate the skills of sonographers. EULAR On-line Introductory Ultrasound Course – This on-line course offers seven modules of theoretical basic skills on ultrasound showing different joint sites, in healthy subjects and in rheumatic diseases, using a wide variety of images and video clips. Each module consists of a main review text with video clips and/or photos, two in-depth discussions expanding on clinical problems and two interactive clinical cases with questions and answers. In addition, assessment questions are presented at the end of each module. The course starts each September and is designed for seven months. Participants finish with an on-line exam and, upon passing, receive a EULAR certificate. Knowledge and skills are targeted at the level felt to be appropriate for European rheumatologists who would like to acquire a basic theoretical knowledge on ultrasound. Participants may later elect to continue with the training program by attending EULAR sonography courses and/or ultrasound courses with EULAR endorsement. Ultrasound Courses with EULAR Scientific Endorsement – In addition to its own branded educational course programme, EULAR invites other ultrasound courses to apply for “EULAR scientific endorsement” according to predefined rules related to the quality of the content, the qualifications of the faculty and the rigor of the course evaluation. To this end, EULAR views scientific endorsement as an opportunity to positively influence the quality of ultrasound training in rheumatology. EULAR Book on Ultrasound in Rheumatology – Essential Applications of Musculoskeletal Ultrasound in Rheumatology assists the readers in most effectively using musculoskeletal ultrasound to diagnose and monitor the progression of rheumatoid arthritis, vasculitis, and other rheumatic and soft tissue disorders. Ultrasound Practical Skills Sessions at EULAR Congress – Ultrasound basic and advanced practical skills sessions are usually included in the scientific programme of the annual EULAR Congress. They consist of a combination of brief lectures and hands-on-scanning of patients with rheumatic diseases and aim at teaching participants how to use ultrasound in clinical practice. References Naredo E, Bijlsma JW, Conaghan PG et al Recommendations for the content and conduct of European League Against Rheumatism (EULAR) musculoskeletal ultrasound courses. Ann Rheum Dis 2008;67:1017-22. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.6309

Musculoskeletal ultrasound (US) is a valuable imaging modality for detecting and quantifying a range of joint pathologies occurring in rheumatic diseases, especially RA. Recently new imaging modalities such as US are emerging as valuable tools for diagnosing, monitoring and remission in RA. US has proven its validity to assess synovitis in RA and has been demonstrated to be superior to clinical examination in the detection of inflammatory abnormalities at joint level [1]. However, RA is characterized by polyarticular and symmetrical involvement of peripheral joints and, in order to be able to assess global disease activity, it is therefore necessary to move from the level of single joints to the level of the patient as a global entity [2]. Thus, the relevance of a global but feasible ultrasonographic assessment surged proposals of different US joint count [3]. The concept of developing an US-based scoring system for synovitis in RA at patient level is based on the need for integrating the components of synovitis (i.e. synovial hypertrophy, synovial Dopper signal and joint effusion) in a unique global score of joint inflammatory activity in RA [4]. The application of a scoring system at patient level by a multi-joint US assessment aims at producing an objective tool for assessing disease activity, monitoring patients under treatment and evaluate the presence of remission [4]. In addition, the availability of a global assessment tool represents a feasible and limited-costs system that is useful in the rheumatology clinical practice as well as in clinical trials. In this context, recent studies applying either extensive or reduced US joint counts have shown the feasibility of US for following patients under treatment. However, currently there is a lack of consensus regarding the optimal number of joints to include in the global assessment as well as the appropriate scoring system to use at single joint level [4]. In addition, many differences in the responsive index applied (i.e. gray-scale synovitis, Doppler, both modalities) as well as in the correlations between US scores and clinical and laboratory findings have been registered [4–10]. Particularly, the proposed scoring systems include a variable number of joints, ranging from a maximum of 78 to a minimum of 6 [3,10]. In between, other innovative US scores have been proposed and include joints selected either bilaterally or at the level only the clinically dominant side of the body [6–8]. More recently, the development of an US global OMERACT synovitis scoring system at patient level has been proposed for being applied in multicenter international therapeutic trials aiming at testing the responsiveness of US scoring system in RA patients [4]. Further randomized controlled studies are needed for confirming these results and explore predictive aspects in respect of development of structural damage and stratification of patients. References Rizzo C et al.Ultrasound in rheumatoid arthritis. Med Ultrason. 2013;15:199-208 Mandl P et al. A systematic literature review analysis of ultrasound joint count and scoring systems to assess synovitis in rheumatoid arthritis according to the OMERACT filter. J Rheumatol. 2011;38:2055-62 Hammer HB et al. A 78-joints ultrasonographic assessment is associated with clinical assessments and is highly responsive to improvement in a longitudinal study of patients with rheumatoid arthritis starting adalimumab treatment. Ann Rheum Dis 2010; 69:1349-51 Iagnocco A et al. Responsiveness in Rheumatoid Arthritis. A Report from the OMERACT 11 Ultrasound Workshop. J Rheumatol. 2014;41:379-82 Naredo E et al. The OMERACT Ultrasound Task Force – Status and Perspectives. J Rheumatol 2011;38:2063-7 Naredo E et al. Power Doppler ultrasonographic monitoring of response to anti-tumor necrosis factor therapy in patients with rheumatoid arthritis. Arthritis Rheum. 2008;58:2248-56 Naredo E et al. Validity, reproducibility, and responsiveness of a twelve-joint simplified power Doppler ultrasonographic assessment of joint inflammation in rheumatoid arthritis. Arthritis Rheum 2008;59:515-2216. Backhaus M et al. Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: A pilot project. Arthritis Rheum 2009;61:1194-201 Iagnocco A et al Clinical and ultrasonographic monitoring of the response to adalimumab treatment in rheumatoid arthritis. J Rheumatol 2008;35:35-40 Perricone C et al. The 6-joint ultrasonographic assessment: a valid, sensitive-to-change and feasible method for evaluating joint inflammation in RA. Rheumatology (Oxford) 2012;51:866-73 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.6184

Background Primary Sjogren9s Syndrome (SS) is an autoimmune disease characterized by early inflammatory abnormalities of salivary and lacrimal glands and subsequent progressive destruction and local fibrosis. Imaging evaluation of salivary gland involvement in SS is still a matter of debate, with different tools that may be used. Ultrasound (US) has high sensitivity and specificity in the evaluation of parotid and submandibular glands involvement in SS (1). Elastography (UE) is a new technique that has been recently used for assessing skin and tendon elasticity in rheumatic diseases (2). However, as far as we know no study is present in the literature about elastographic assessment of salivary gland in SS. Objectives To evaluate the involvement of salivary glands in SS by UE and to correlate elastographic findings with US-detected abnormalities. Methods Salivary glands of consecutive SS patients and healthy controls were examined by UE and US by an experienced ultrasonographer who was blinded to the clinical findings. The study was performed with a MyLab70 XVG (Esaote,Italy) machine equipped with a multifrequency linear probe (4-13 MHz) and elastographic software. Parotid and submandibular glands were studied bilaterally by US firstly and graded according to a 0-4 score (1). Then, UE was carried out by sequential movements of compression and decompression of the probe over the region of interest and the resulting color assessment varied from red (indicative of soft and highly elastic tissue), to green (which represented intermediate elastic tissue), and to blue (which denoted hard and barely elastic tissue). Elastographic findings were scored according to the local color prevalence. The association between US and UE score was evaluated by the Spearman9s correlation coefficient, and discrimination between cases and control by the area under the ROC curve (AUC). Results 328 salivary glands of 82 patients with SS [80 (97.6%) female; mean (sd) age 53.5 (12.3); median (IQR) disease duration in months 21 (1-192) and 116 glands of 29 aged matched healthy individuals [21 (72.4%) female; mean (sd) age 48.7 (13.5)] were studied. A significant correlation between the total UE and the US score was found (0.68; p Conclusions UE is a valuable imaging tool in the assessment of salivary gland abnormalities in SS patients and may represent a good option as a first-line imaging modality in the diagnostics of the disease. References Salaffi F, Carotti M, Iagnocco A et al Ultrasonography of salivary glands in primary Sjogren9s syndrome: a comparison with contrast sialography and scintigraphy. Rheumatology 2008;47:1244-9. Iagnocco A, Kaloudi O, Perella C et al Ultrasound elastography assessment of skin involvement in systemic sclerosis: lights and shadows. J Rheumatol 2010;37:1688-91 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3419

Background Osteoarthritis (OA) is the most common form of arthritis and a major socioeconomic burden. Preventive measures and early treatments are considered most effective in OA, but biomarkers to detect very early stages of OA or to predict the course of the disease are not available. Micro RNAs (miRNAs), which are stable and easily accessible in the peripheral circulation, are emerging as biomarkers for various physiological and pathological conditions. Objectives To explore the association between serum miRNAs and the development of severe osteoarthritis of the knee and hip joint in the general population. Methods Using the well-defined Bruneck cohort, we followed 816 Caucasian individuals from 1995 to 2010 and assessed joint arthroplasty as a definitive outcome of severe osteoarthritis of the knee and hip. A microarray screening identified candidate miRNAs in two OA serum pools, which we validated by qPCR in the entire cohort using U6 and Ct average as two independent methods for normalization. Results During the 15-year follow-up, 67 of a total of the 816 individuals had one or more total joint replacement surgeries for severe knee or hip OA corresponding to an intervention rate of 6.9 per 1000 person-years. The body-mass index was significantly increased in subjects receiving arthroplasty for OA (P=0.002), and there was a trend towards an increased age among individuals with arthroplasty (P=0.053). The microarray screening identified 12 candidate miRNAs, which we validated by qPCR in the entire cohort. After this validation, cox regression analysis demonstrated that 3 miRNAs were associated with severe knee and hip osteoarthritis. Let-7e was a negative predictor for total joint arthroplasty with an adjusted HR of 0.75 (CI: 0.58 to 0.96; P=0.021) when normalized to U6, and 0.76 (CI: 0.6 to 0.97; P=0.026) after normalization to the Ct-average. miR-454 was inversely correlated with severe knee or hip osteoarthritis with an adjusted HR of 0.77 (CI: 0.61 to 0.97; P=0.028) when normalized to U6. This correlation was lost when data were normalized to Ct-average (P=0.118). Finally, miR-885-5p showed a trend towards a positive relationship with arthroplasty when normalized to U6 (HR of 1.24; CI: 0.95 to 1.62; P=0.107) or to Ct-average (HR of 1.30; CI: 0.99 to 1.70; P=0.056). MiRNA relevance network analysis further supported a putative role of miRNAs as OA biomarkers, since OA was characterized by substantial edge rewiring around let-7e as well as miR-454 and miR-885-5p. Conclusions Our study is the first to identify differentially expressed circulating miRNAs in osteoarthritis patients necessitating arthroplasty in a large, population-based cohort. Among these miRNAs, let-7e emerged as potential predictor for severe knee or hip osteoarthritis. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1839

Background The global power Doppler ultrasound (PDUS) scoring system combining synovial hypertrophy, joint effusion and PD signal developed by the OMERACT-EULAR-US Task Force has good intra- and inter-observer reliability in metacarpophalangeal (MCP) and non-MCP joints and demonstrates consistency between PDUS machines. 1 We present the first international, Phase IIIb study using the global PDUS synovitis score to assess early impact of IV abatacept (ABA) on synovial inflammation. Objectives Primary objective: to evaluate early response to ABA, defined by improvement of synovitis assessed by global PDUS of affected MCP joints bilaterally. Methods This 6-mth, single-arm, open-label study enrolled active MTX-IR RA patients (pts) defined as DAS28 (CRP) >3.2 or ≥6 tender and swollen joints and CRP >ULN. Pts had a total synovitis PDUS score >1 for ≥2 MCPs and ≥1 for ≥1 other MCP (out of MCP 2–5 bilaterally; i.e. 8 joints) at screening and baseline (BL). Global PDUS was scored over 8 MCP joints (range 0–24 units) at BL, Days 7, 15, 29, 43 and 57 then monthly by a PDUS reader blinded from clinical assessments. Early signs of improvement were defined as the earliest timepoint when 95%CI for mean change from BL in global PDUS score did not contain 0 for that and all later timepoints. DAS28 (CRP) and safety were assessed for all pts who received ≥1 dose of ABA. Results 104 pts were enrolled; 89 completed the trial. Demographic, clinical and PDUS data are shown (Table). Early signs of improvement in global PDUS score were observed at Day 7. Mean change from BL in global PDUS score and its components increased to Day 169. By Day 57, threshold for clinically meaningful improvement of 1.2 was not included in the 95% CI for mean change from BL in DAS28 (CRP). There were no deaths; 6 (5.8%) pts developed a SAE (atrial fibrillation, bursitis, dementia, endometriosis, pleural effusion and pulmonary fistula, and hypertension), 62 (59.6%) an AE, and 20 (19.2%) an infection. Conclusions The study showed that the OMERACT-EULAR-US global PDUS score detected early signs of improvement in synovitis, demonstrating a significant response to abatacept at Day 7, which increased to Mth 6. Efficacy and safety data were consistent with a previous abatacept trial in MTX-IR pts. 2 References Naredo E et al. J Rheumatol 2011;38:2063–7; Conaghan P et al. Ann Rheum Dis 2011;70(S3):151. Disclosure of Interest M. D’Agostino: None Declared, R. Wakefield: None Declared, H. Berner Hammer: None Declared, O. Vittecoq: None Declared, M. Galeazzi: None Declared, P. Balint Grant/Research support from: Bristol-Myers Squibb, Speakers Bureau: Abbott, Pfizer, MSD, Roche, SonoSite, GE, ESAOTE, ACR, EULAR, E. Fillipucci Consultant for: Bristol-Myers Squibb, I. Moller: None Declared, A. Iagnocco: None Declared, E. Naredo Grant/Research support from: Merck Sharp & Dohme Corp, M. Ostergaard Grant/Research support from: Abbott, Amgen, Bristol-Myers Squibb, Centocor, Genmab, Glaxo-Smith-Kline, Mundipharma, Novo, Pfizer, Roche, Schering-Plough, UCB and Wyeth, Consultant for: Abbott, Amgen, Bristol-Myers Squibb, Centocor, Genmab, Glaxo-Smith-Kline, Mundipharma, Novo, Pfizer, Roche, Schering-Plough, UCB and Wyeth, Speakers Bureau: Abbott, Amgen, Bristol-Myers Squibb, Centocor, Genmab, Glaxo-Smith-Kline, Mundipharma, Novo, Pfizer, Roche, Schering-Plough, UCB and Wyeth, C. Gaillez Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb, W. Kerselaers Employee of: Bristol-Myers Squibb, K. Van Holder Employee of: Bristol-Myers Squibb, M. Le Bars Shareholder of: Bristol-Myers Squibb, Employee of: Bristol-Myers Squibb

Background Pathogenesis of osteoarthritis may have a strong metabolic component. Thus, alterations in glucose metabolism such as diabetes mellitus may be linked to the development of osteoarthritis. Objectives To evaluate if diabetes mellitus is an independent risk factor for severe osteoarthritis. Methods Population-based cohort study with a random sample of 927 men and women aged 40 to 80 years followed over 20 years (1990-2010) at the City of Bruneck/Northern Italy. Hazard ratios for arthroplasty were calculated in diabetic and non- diabetic subjects by using age, sex and body mass index-adjusted as well as multivariable models. Results Rates of arthroplasty were 17.7 (9.4-30.2)/1000 person-years in diabetic and 5.3 (4.1-6.6)/1000 person-years in non-diabetic subjects (P Conclusions Diabetes mellitus predicts the development of severe OA. This association is independent of age and body mass index, which are the best- established risk factors for OA to date. Our findings strengthen the concept of a strong metabolic component in the pathogenesis of OA and suggest that effective management of OA needs to include the prevention and treatment of diabetes mellitus. Disclosure of Interest None Declared

Background Several ultrasound (US) scoring systems have been proposed for evaluating objectively RA patients’ responsiveness under treatment [1-3]. Objectives To evaluate the sensitivity to change over one year of a combined gray-scale (GS) and power Doppler (PD) US score in RA patients taking different anti-rheumatic therapies in comparison to synovitis sum scores of 5 joints (US5). Methods USdata of 77 RA patients have been surveyed over the time of one year since inclusion of each patient. The clinically most affected hand (wrist and finger joints) was semi-quantitatively (0-3) assessed by GS and PDUS for synovitis (synovial fluid and/or synovial hypertrophy) [4]. In detail, radiocarpal, ulnocarpal and midcarpal wrist as well as the MCP2-5 and PIP2-5 joints were examined from dorsal and palmar at baseline, and 3, 6, 12 months after initiation/change of therapy (DMARD/Biologic). The combined score was the highest of either the GS or PDUS score with the same weight at joint level [5]. Each combined score was correlated to the 5-joint sum score of the wrist and hand (dorsal ulnocarpal, dorsal and palmar midcarpal regions, dorsal (only PDUS) and palmar MCP2,3 and PIP2,3 regions according to [2] without forefoot) at patient level each in GS and PDUS. Clinical examination by DAS28 was performed at the same time points than US. Correlations between the combined scores, the GS/PDUS5, and DAS28 were obtained by Spearman’s correlation coefficient. Results After baseline examination, 71.2% of included patients were on Biologic and 28.8% on DMARD therapy. The combined scores demonstrated longitudinal significant correlations with the DAS28 only in the dorsal midcarpal (r=0.29, p=0.015) and ulnocarpal (r=0.24, p=0.47) wrist regions, whereas the US5 sum score presented higher significant correlations both in GS (r=0.42, p Conclusions Considering the whole patient group independently from therapy, the proposed combined score was only sensitive to change at the wrist joint level (dorsal midline and ulnocarpal) under different anti-rheumatic therapies. The US5 sum score was higher responsive independently from the US modality (GS/PDUS). References Naredo E, et al. Clin Exp Rheumatol 2005;23(6):881-4. Backhaus M, et al. Arthritis Rheum 2009;61(9):1194-1201. Perricone C, et al. Rheumatology (Oxford) 2012;51:866-73. Wakefield RJ, et al. J Rheumatol 2005;32:2485–7. Naredo E, et al. J Rheumatol. 2011 Sep;38(9):2063-7. Disclosure of Interest None Declared

Background Extremity-dedicated MRI is a sensitive method to detect early inflammatory and destructive changes in peripheral joints of RA patients, while reducing costs and decreasing patient’s discomfort. Objectives The objective of this phase IIIb, national, multicentre, open-label study (Eudract n 2009 012185-32) was to assess the effects of TCZ in combination with DMARDs on changes of the synovial membrane enhancement in the wrist joints of RA patients with inadequate response to DMARDs. Methods TCZ 8mg/kg IV was given every 4 wks for a total of 12 infusions. MRI was performed with a dedicated 0.2T machine (Esaote, Genova, Italy) using pre and post-contrast T1 weighted Turbo 3D, fast T1 weighted Spin Echo in the axial plane, and STIR sequences, at baseline and after 2, 4, 12, 24 and 48 weeks. Changes from baseline to wk 4 in extension and degree of wrist synovitis measured with RA MRI score (RAMRIS) and in quantitative assessment with dynamic, gadolinium-enhanced MRI, were the primary endpoints. Secondary efficacy endpoints were measured up to 48 wks from treatment start. Adverse events (AEs), vital signs and laboratory tests were the safety measures. Results 58 pts (mean age 51.5 yrs, 78% females, median RA duration 5 yrs) received TCZ (ITT sample) and 8 (13.8%) were discontinued. Mean (±SD) RAMRIS score, but not the dynamic parameters rate of early enhancement (REE) and relative enhancement (RE), significantly decreased from baseline to wk 4 (-0.804±1.575, p=0.018 by Wilcoxon’s sign test). Consistent findings were observed in the per-protocol sample (43 pts). In the repeated measures ANOVA model, RAMRIS significantly decreased after only 2 wks and up to wk 48; RE and REE decreased at wk 24 and at wks 12, 24 and 48, respectively. The mean RAMRIS score of bone marrow edema of wrist and metacarpo-phalangeal joints significantly decreased from baseline to wks 24 (-6.70±10.98, p=0.0022) and 48 (-8.30±13.061, p=0.0008), while bone erosion score did not progress. Mean DAS-28 CRP decreased from 5.44±0.90 at baseline to 2.35±1.37 at wk 48. Significant improvement from baseline to wk 48 (p Conclusions This is the first study evaluating the effect of TCZ in RA patients by contrast-enhanced MRI. TCZ 8mg/kg given in combination with DMARDs in RA pts not responsive to DMARDs therapy was associated with rapid improvements not only of clinical parameters, but also of MRI wrist synovitis and bone marrow edema, with no progression in bone erosions. The safety results were in line with the known profile of TCZ. Disclosure of Interest None Declared

Musculoskeletal ultrasound (US) is a valuable imaging modality for detecting and quantifying a range of joint pathologies occurring in rheumatic diseases (1-2). In inflammatory arthritis and in osteoarthritis (OA) it is able to show early and late findings including cartilage lesions (1-4). Normal hyaline cartilage is imaged by US as a homogeneously anechoic layer lining the bony cortex and having a superficial and a deep margin that appear thin, sharp, continuous and regularly hyperechoic. In OA, loss of the anechoic echotexture, irregularities and loss of sharpness of the margins and progressive thinning of cartilage layer are visualized (1). With disease progression, focal and asymmetric narrowing is usually present up to the complete absence of the cartilaginous layer and cartilage breakdown (5). US has been demonstrated to be a reliable tool for assessing cartilage abnormalities in hand joints of OA patients (1). In rheumatoid arthritis (RA) US detects loss of the sharpness of the cartilage margins, partial or full-thickness defects and complete loss of the cartilage with subchondral bone involvement (6). In addition, cartilage US measurements can be performed at different joint sites (7-10). In crystal arthropathy, the conformation and anatomical location of crystals at cartilage level help in differentiating gout and calcium pyrophosphate deposition disease (CPDD) (11). Hyperechoic enhancement of the superficial margin of the hyaline cartilage is visualized in gout and hyperechoic spots within the cartilage layer are imaged in CPDD. In gout, urate crystals deposit over the superficial margin of the cartilage (double contour sign) with focal or diffuse enhancement of the superficial cartilage margin, whose reflectivity is independent of the angle of insonation. In CPDD, pyrophosphate deposits are visualized within the cartilage layer and the double contour aspect is shown as a thin hyperchoic band with focal, punctate or diffuse features. High sensitivity, specificity and accuracy of US in detecting urate and pyrophosphate crystals deposits at knee cartilage level have been recently reported (11). All cartilaginous changes need to be assessed by using a correct US scanning technique, based on appropriate patient positioning to allow the sonographic beam to penetrate the joint, adequate probe orientation to obtain perpendicular insonation of the US beam and assessment of the contralateral site to perform complete and deep comparisons (5). Key messages : US detects a wide range of cartilage abnormalities in OA, RA and crystal related arthropathies. Mandatory technical aspects should be taken into account when assessing the hyaline cartilage (correct machine setting, multiplanar assessment, dynamic evaluation and comparisons with contralateral side) with limited applications to some anatomic areas, depending on the presence of appropriate acoustic windows. References Iagnocco A et al. The reliability of musculoskeletal ultrasound in the detection of cartilage abnormalities at the metacarpo-phalangeal joints. Osteoarthritis Cartilage 2012 Filippucci E et al. Ultrasound imaging for the rheumatologist. Clin Exp Rheumatol 2006 Keen HI et al. Can ultrasonography improve on radiographic assessment in osteoarthritis of the hands? A comparison between radiographic and ultrasonographic detected pathology. Ann Rheum Dis 2007 Iagnocco A et al. High resolution ultrasonography in detection of bone erosions in patients with hand osteoarthritis. J Rheumatol 2005 Iagnocco A. Imaging the joint in osteoarthritis: a place for ultrasound? Best Pract Res Clin Rheumatol 2010 Filippucci E et al. Interobserver reliability of ultrasonography in the assessment of cartilage damage in rheumatoid arthritis. Ann Rheum Dis 2010 Moller B et al. Measuring finger joint cartilage by ultrasound as a promising alternative to conventional radiograph imaging. Arthritis Rheum 2009 Aisen AM et al Sonographic evaluation of the cartilage of the knee. Radiology 1984 Iagnocco A et al Sonographic evaluation of femoral condylar cartilage in osteoarthritis and rheumatoid arthritis. Scand J Rheumatol 1992 Naredo E et al Ultrasound validity in the measurement of knee cartilage thickness. Ann Rheum Dis 2009 Filippucci E et al. Hyaline cartilage involvement in patients with gout and calcium pyrophosphate deposition disease. An ultrasound study. Osteoarthritis Cartilage 2009 Disclosure of Interest None Declared