Search

International audience; Objective: This study aimed to develop (1) a new ultrasound definition for aggregates and (2) a semi-quantitative ultrasound scoring system (0–3) for tophus, double contour and aggregates. Furthermore, the intra- and inter-reader reliabilities of both the re-defined aggregates and the semi-quantitative scoring system were assessed using static image exercises. Methods: Thirty-seven rheumatologists were invited. A Delphi process was used for re-defining aggregates and for selecting a semi-quantitative scoring system with >75% agreement obligate for reaching consensus. Subsequently, a web-based exercise on static ultrasound images was conducted in order to assess the reliability of both the re-defined aggregates and the semi-quantitative scoring system. Results: Twenty rheumatologists contributed to all rounds of the Delphi and image exercises. A consensual re-definition of aggregates was obtained after three Delphi rounds but needed an overarching principle for scoring aggregates in patients. A consensus-based semi-quantitative ultrasound scoring system for gout lesions was developed after two Delphi rounds. The re-definition of aggregates showed good intra- and inter-reader reliability (κ-values 0.71 and 0.61). The reliabilities of the scoring system were good for all lesions with slightly higher intra-reader (κ-values 0.74–0.80) than inter-reader reliabilities (κ-values 0.61–0.67). Conclusion: A re-definition of aggregates was obtained with a good reliability when assessing static images. The first consensus-based semi-quantitative ultrasound scoring system for gout-specific lesions was developed with good inter- and intra-reader reliability for all lesions when tested in static images. The next step is to assess the reliabilities when scoring lesions in patients.

Background: Aspiration and injection of joints and soft tissues is an indispensable skill used in everyday practice by the clinical rheumatologist. These tasks are usually conducted by palpation-guided techniques. These procedures are not always successful (1) and thus US -guided interventions have been developed. Objectives: are to explain the effect of needle and sound beam angle on needle visualization, describe different techniques of needle insertion under US guidance, to identify different approaches to the target under US guidance and finally to discuss about the accuracy and efficacy of the ultrasound guided technique. Methods: There are two common methods for US puncturing: semi-guided or indirect method (skin surface marking) and needle guidance under direct sonographic vision (2,3). The scanning plane is optimized for visualization of the target and penetration of the needle should be at least 0.5cm from the transducer. The movement of the needle in the soft tissue should be followed on the screen during the procedure. The needle appears as a bright echoic line if the transducer is oriented longitudinally on the needle, and the needle tip may be followed as it reaches the target. If the ultrasound beam is transverse to the needle, the needle is seen as a bright echoic dot. In case of no visualization of the needle several means are available: steering of the ultrasound beam against the needle (in new machines), curved or virtual convex probe, toeing -in of the probe, shaken the needle slightly and moving the probe a bit from side to side. Results: According to the clinical and cadaveric studies the ultrasound guided technique is more accurate than the landmark guided technique in the glenohumeral, acromioclavicular, wrist, hand, hip, knee and foot joints and in the tendons of the biceps, wrist, hand hip, knee and ankle (4). Synovial biopsies are more accurate using an ultrasound guided method (5). Conclusion: Ultrasound is the most applicable and feasible imaging modality for routine clinical use in guiding musculoskeletal procedures. Though many studies have examined the role of imaging guidance for injection there needs to be more examination of how the use of ultrasound prior to injection can alter the pathological and anatomical diagnosis. There is a trend towards an expanded number of advanced applications of interventional musculoskeletal ultrasound which can also be performed by a rheumatologist like nerve blocks or needling of calcifications. Which ultrasound guided technique (direct or semi-guided) is the most appropriate in different anatomical areas and clinical settings remains to be studied. More studies are needed to show the accuracy and efficacy of ultrasound guided injections in different anatomical areas (4). References: [1] Jones A, et al. Importance of placement of intra-articular steroid injections. BMJ 1993;307:1329-1330. [2] Koski JM. Ultrasound guided injections in rheumatology. J Rheumatol 2000;7:2131-8. [3] Fessell DP, et al. Using sonography to reveal and aspirate joint effusions. AJR 2000;174:1353-62. [4] Kane D, Koski JM. Musculoskeletal interventional procedures: With or without imaging guidance? In Clinical Rheumatology. Best Practice & Research Clinical Rheumatology, 2016:736-750. [5] Kelly S, et al. Ultrasound-guided synovial biopsy: a safe, well-tolerated and reliable technique for obtaining high-quality synovial tissue from both large and small joints in early arthritis patients. Ann Rheum Dis 2015;74:611-617. Disclosure of Interests: None declared

Purpose To evaluate adiabatic T1ρ and T2ρ of articular cartilage in symptomatic osteoarthritis (OA) patients and asymptomatic volunteers, and to determine their association with magnetic resonance imaging (MRI)-based structural abnormalities in cartilage and bone. Materials and methods A total of 24 subjects (age range: 50-68 years; 12 female) were enrolled, including 12 early OA patients and 12 volunteers with normal joint function. Patients and volunteers underwent 3T MRI. T2 , adiabatic T1ρ , and T2ρ relaxation times of knee articular cartilage were measured. Proton density (PD)- and T1 -weighted MR image series were also obtained and separately evaluated for morphological changes using the MRI OA Knee Scoring (MOAKS) system. Comparisons using the Mann-Whitney nonparametric test were performed after dividing the study participants according to physical symptoms as determined by Western Ontario and McMaster Universities (WOMAC) score or presence of cartilage lesions, bone marrow lesions, or osteophytes. Results Elevated adiabatic T1ρ and T2ρ relaxation times of articular cartilage were associated with cartilage loss (P = 0.024-0.047), physical symptoms (0.0068-0.035), and osteophytes (0.0039-0.027). Elevated adiabatic T1ρ was also associated with bone marrow lesions (0.033). Conclusion Preliminary data suggest that elevated adiabatic T1ρ and T2ρ of cartilage are associated with morphological abnormalities of cartilage and bone, and thus may be applicable for in vivo OA research and diagnostics. Level of evidence 2 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2017;46:678-689.

Summary Objective To determine the associations between multi-feature structural pathology assessed using magnetic resonance imaging (MRI) and the presence of knee pain, and to determine the associations between the locations of structural changes and different knee pain patterns. Method Eighty symptomatic subjects with knee pain and suspicion or diagnosis of knee OA and 63 asymptomatic subjects underwent knee MRI. Severity of structural changes was graded by MRI Osteoarthritis Knee Score (MOAKS) in separate knee locations. The associations between cartilage damage, bone marrow lesions (BMLs), osteophytes, Hoffa's synovitis, effusion-synovitis, meniscal damage and structural pathologies in ligaments, tendons and bursas and both the presence of pain and the knee pain patterns were assessed. Results The presence of Hoffa's synovitis (adjusted RR 1.6, 95% CI 1.2–1.3) and osteophytes in any region (2.07, 1.19–3.60) was significantly associated with the presence of pain. Any Hoffa's synovitis was associated with patellar pain (adjusted RR 4.70, 95% CI 1.19–3.60) and moderate-to-severe Hoffa's synovitis with diffuse pain (2.25, 1.13–4.50). Medial knee pain was associated with cartilage loss in the medial tibia (adjusted RR 2.66, 95% CI 1.22–5.80), osteophytes in the medial tibia (2.66, 1.17–6.07) and medial femur (2.55, 1.07–6.09), medial meniscal maceration (2.20, 1.01–4.79) and anterior meniscal extrusions (2.78, 1.14–6.75). Conclusions Hoffa's synovitis and osteophytes were strongly associated with the presence of knee pain. Medial pain was associated most often with medially located structural pathologies.

Aspiration and injection of joints and soft tissues is an indispensable skill used in everyday practice by the clinical rheumatologist. Most rheumatologists recognise that performing these procedures using anatomical landmarks is not always successful, particularly in the case of small or infrequently injected joints, bursae or tendon sheaths. Musculoskeletal ultrasound confirms the local pathological-anatomical diagnosis and is the most applicable and feasible imaging method that can be applied in clinical practice in guiding musculoskeletal interventional procedures. From 1993, there has been substantial examination of the accuracy of landmark- and imaging-guided procedures. We have searched the literature and ascertained whether imaging techniques improve the accuracy of musculoskeletal procedures and whether the accuracy of needle placement can be translated into improved clinical outcome (efficacy).

The purpose of this study was to assess the effectiveness of the ultrasonography (US) on detecting osteoarthritis of the knee, and compare US and radiographic findings to intraoperative total knee arthroplasty (TKA) findings. Fifty-seven late-stage osteoarthritic knees undergoing TKA were evaluated with US and radiography. Standard knee US assessing femoral cartilage damage, osteophytes, effusion, synovitis, and meniscal extrusion was performed. On radiographs, osteophytes, joint space narrowing, and Kellgren-Lawrence grade were evaluated. Corresponding intra-operative findings were assessed during TKA as the gold standard. On the damage of the medial femoral condyle cartilage, the sensitivity of US was high (92%), whereas on the lateral condyle and sulcus area, sensitivities were 58% and 46%, respectively. On osteophytes, the detection rate of the US was remarkable especially on the medial side yielding sensitivities of 90–95%. The sensitivities for detecting effusion and synovitis were also excellent (97%). US detection rate of femoral cartilage damage was in concordance with the radiographic joint space narrowing. For the detection of osteophytes, US provided superior results to radiography particularly on the medial side. In conclusion, US can reliably assess the late-stage OA changes of the knee especially on the medial side of the knee joint.

BackgroundIn 2001, the European League Against Rheumatism developed and disseminated the first guidelines for musculoskeletal (MS) ultrasound (US) in rheumatology. Fifteen years later, the dramatic expansion of new data on MSUS in the literature coupled with technological developments in US imaging has necessitated an update of these guidelines.ObjectivesTo update the existing MSUS guidelines in rheumatology as well as to extend their scope to other anatomic structures relevant for rheumatology.MethodsThe project consisted of the following steps: (1) a systematic literature review of MSUS evaluable structures; (2) a Delphi survey among rheumatologist and radiologist experts in MSUS to select MS and non-MS anatomic structures evaluable by US that are relevant to rheumatology, to select abnormalities evaluable by US and to prioritise these pathologies for rheumatology and (3) a nominal group technique to achieve consensus on the US scanning procedures and to produce an electronic illustrated manual (ie, App of these procedures).ResultsStructures from nine MS and non-MS areas (ie, shoulder, elbow, wrist and hand, hip, knee, ankle and foot, peripheral nerves, salivary glands and vessels) were selected for MSUS in rheumatic and musculoskeletal diseases (RMD) and their detailed scanning procedures (ie, patient position, probe placement, scanning method and bony/other landmarks) were used to produce the App. In addition, US evaluable abnormalities present in RMD for each anatomic structure and their relevance for rheumatology were agreed on by the MSUS experts.ConclusionsThis task force has produced a consensus-based comprehensive and practical framework on standardised procedures for MSUS imaging in rheumatology.

The aetiology of knee pain in osteoarthritis (OA) is heterogeneous and its relationship with structural changes and function is unclear. Our goal was to determine the prevalence of wide-area scanned ultrasound-defined knee OA structural features and their association with pain and functional impairment in 79 symptomatic and 63 asymptomatic subjects. All subjects underwent ultrasound knee wide-area scanning and the severity of articular cartilage degeneration, the presence and size of osteophytes, and meniscal extrusion were evaluated. Subjects filled in a self-administrated questionnaire on present knee pain, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) on clinical symptoms and function over the past week. Cartilage changes were the most prevalent followed by lateral meniscal extrusion, osteophytes and medial meniscal extrusion. The global femoral cartilage grade associated strongly with pain and the WOMAC index. Site-specifically, early medial cartilage changes and thinning in sulcus and lateral site were associated with symptoms. The presence of femoral lateral osteophytes was also associated with both outcomes. Using the novel wide-area ultrasound scanning technique, we were able to confirm the negative impact of femoral cartilage OA changes on clinical symptoms. Presence, not necessarily size, of lateral femoral osteophytes was also associated with increased pain and disability., published version, peerReviewed

Objective The main aim was to investigate the associations between Magnetic Resonance Imaging (MRI)-defined structural pathologies of the knee and physical function. Design A cohort study with frequency matching on age and sex with eighty symptomatic subjects with knee pain and suspicion or diagnosis of knee osteoarthritis (OA) and 57 asymptomatic subjects was conducted. The subjects underwent knee MRI, and the severity of structural changes was graded by MRI Osteoarthritis Knee Score (MOAKS) in separate knee locations. WOMAC function subscores were recorded and physical function tests (20-m and 5-min walk, stair ascending and descending, timed up & go and repeated sit-to-stand tests) performed. The association between MRI-defined structural pathologies and physical function tests and WOMAC function subscores were evaluated by linear regression analysis with adjustment for demographic factors, other MRI-features and pain with using effect size (ES) as a measure of the magnitude of an association. Results Cartilage degeneration showed significant association with poor physical performance in TUG-, stair ascending and descending-, 20-m- and 5-min walk-tests (ESs in the subjects with cartilage degeneration anywhere between 0.134 [95%CI 0.037–0.238] and 0.224 [0.013–0.335]) and with increased WOMAC function subscore (ES in the subjects with cartilage degeneration anywhere 0.088 [0.012–0.103]). Also, lateral meniscus maceration and extrusion were associated with poor performance in stair ascending test (ESs 0.067 [0.008–0.163] and 0.077 [0.012–0.177]). Conclusions After adjustments cartilage degeneration was associated with both decreased self-reported physical function and poor performance in the physical function tests. Furthermore, subjects with lateral meniscus maceration and extrusions showed significantly worse performance in stair ascending tests., final draft, peerReviewed

To evaluate adiabatic TA total of 24 subjects (age range: 50-68 years; 12 female) were enrolled, including 12 early OA patients and 12 volunteers with normal joint function. Patients and volunteers underwent 3T MRI. TElevated adiabatic TPreliminary data suggest that elevated adiabatic T2 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2017;46:678-689.

Osteoarthritis (OA) is a common degenerative musculoskeletal disease highly prevalent in aging societies worldwide. Traditionally, knee OA is diagnosed using conventional radiography. However, structural changes of articular cartilage or menisci cannot be directly evaluated using this method. On the other hand, ultrasound is a promising tool able to provide direct information on soft tissue degeneration. The aim of our study was to systematically determine the site-specific diagnostic performance of semi-quantitative ultrasound grading of knee femoral articular cartilage, osteophytes and meniscal extrusion, and of radiographic assessment of joint space narrowing and osteophytes, using MRI as a reference standard. Eighty asymptomatic and 79 symptomatic subjects with mean age of 57.7 years were included in the study. Ultrasound performed best in the assessment of femoral medial and lateral osteophytes, and medial meniscal extrusion. In comparison to radiography, ultrasound performed better or at least equally well in identification of tibio-femoral osteophytes, medial meniscal extrusion and medial femoral cartilage morphological degeneration. Ultrasound provides relevant additional diagnostic information on tissue-specific morphological changes not depicted by conventional radiography. Consequently, the use of ultrasound as a complementary imaging tool along with radiography may enable more accurate and cost-effective diagnostics of knee osteoarthritis at the primary healthcare level.

US allows us to detect joint alterations and to perform procedures such as aspiration of fluid as well as therapeutic injections; it helps in placing the needle correctly, greatly improving the outcome. Tissue biopsies (of, for example, synovium, muscle or salivary glands) can be performed with US guidance, and this method may be of significant importance in diagnostic examinations. Other imaging methods may be fused with US, and thus detailed maps are available to navigate in soft tissues. The new era in rheumatology will include US as an important part of its armament.

SummaryObjectiveTo investigate the diagnostic performance of non-invasive knee ultrasonography (US) to detect degenerative changes of articular cartilage using arthroscopic grading as the gold standard.DesignForty adult patients referred to a knee arthroscopy because of knee pain were randomly selected for the study. Before the arthroscopy, knee US was performed and cartilage surfaces at medial and lateral femoral condyles as well as at intercondylar notch area (sulcus) were semi-quantitatively graded from US. Ultrasonographic grading was compared with the arthroscopic Noyes’ grading for cartilage degeneration.ResultsSensitivity, specificity, positive predictive value, negative predictive value, and diagnostic odds ratio for detecting arthroscopic cartilage changes in US varied between 52 and 83%, 50–100%, 88–100%, 24–46%, and 5.0–13.0, respectively, depending on the site. Correlation of severity of cartilage changes (grades) between US and arthroscopy varied from insignificant to significant depending on the site: at the sulcus area the correlation was highest (rs=0.593, P

Article, Osteoarthritis (OA) is a common degenerative musculoskeletal disease highly prevalent in aging societies worldwide. Traditionally, knee OA is diagnosed using conventional radiography. However, structural changes of articular cartilage or menisci cannot be directly evaluated using this method. On the other hand, ultrasound is a promising tool able to provide direct information on soft tissue degeneration. The aim of our study was to systematically determine the site-specific diagnostic performance of semi-quantitative ultrasound grading of knee femoral articular cartilage, osteophytes and meniscal extrusion, and of radiographic assessment of joint space narrowing and osteophytes, using MRI as a reference standard. Eighty asymptomatic and 79 symptomatic subjects with mean age of 57.7 years were included in the study. Ultrasound performed best in the assessment of femoral medial and lateral osteophytes, and medial meniscal extrusion. In comparison to radiography, ultrasound performed better or at least equally well in identification of tibio-femoral osteophytes, medial meniscal extrusion and medial femoral cartilage morphological degeneration. Ultrasound provides relevant additional diagnostic information on tissue-specific morphological changes not depicted by conventional radiography. Consequently, the use of ultrasound as a complementary imaging tool along with radiography may enable more accurate and cost-effective diagnostics of knee osteoarthritis at the primary healthcare level., published version, peerReviewed

To investigate intra- and inter-reader agreement of ultrasonography (US) and conventional radiography (CR) for the evaluation of osteophyte presence and size within the tibiofemoral joint. In addition, to correlate these findings with arthroscopic degeneration of the articular cartilage.Forty adult patients with knee pain were enrolled in this study. Knee CR and US scanning of the medial and lateral bone margins were performed on all patients. A novel atlas for the US grading of knee osteophytes was used in the evaluation. The number and size of the osteophytes were evaluated semi-quantitatively in two rounds from both the CR images (four readers) and the US images (14 readers). The Noyes grading system was used for the evaluation of arthroscopic degeneration of the articular cartilage in 26 patients.On average, intra- and inter-reader US and CR agreement was substantial and comparable to each other (κ = 0.60-0.72). US detected more osteophytes than CR at both the medial (65% vs. 48%) and lateral (70% vs. 60%) compartments. A statistically significant correlation between CR- or US-based osteophyte and arthroscopy grades was observed only for US at the medial compartment (rs = 0.747, p 0.001).The detection of knee osteophytes using the novel US atlas is as reproducible as reading conventional radiographs. US is more sensitive to detect knee osteophytes than CR. Furthermore, osteophytes detected with US correlate significantly with arthroscopic cartilage changes at the medial knee compartment whereas those detected by CR do not.

In the article titled “In vivo quantitative ultrasound image analysis of femoral subchondral bone in knee osteoarthritis” [1], there was an error in the data set (scatter plot) of provided Figure 2(d). The correlation, however, was correct and consequently it does not change our conclusions. Here we provide Figure 2(d) with the corrected data set. Additionally, in Figure 2(a) the mathematical expression of P value was corrected from “P = 0.000” to more appropriate “P < 0.001.”

To examine the validity of power Doppler ultrasound imaging to identify synovitis, using histopathology as gold standard, and to assess the performance of ultrasound equipments.44 synovial sites in small and large joints, bursae and tendon sheaths were depicted with ultrasound. A synovial biopsy was performed on the site depicted and a synovial sample was taken for histopathological evaluation. The performance of three ultrasound devices was tested using flow phantoms.A positive Doppler signal was detected in 29 of 35 (83%) of the patients with active histological inflammation. In eight additional samples, histological examination showed other pathological synovial findings and a Doppler signal was detected in five of them. No significant correlation was found between the amount of Doppler signal and histological synovitis score (r = 0.239, p = NS). The amount of subsynovial infiltration of polymorphonuclear leucocytes and surface fibrin correlated significantly with the amount of power Doppler signal: r = 0.397 (p0.01) and 0.328 (p0.05), respectively. The ultrasound devices differed in showing the smallest detectable flow.A negative Doppler signal does not exclude the possibility of synovitis. A positive Doppler signal in the synovium is an indicator of an active synovial inflammation in patients. A Doppler signal does not correlate with the extent of the inflammation and it can also be seen in other synovial reactions. It is important that the quality measurements of ultrasound devices are reported, because the results should be evaluated against the quality of the device used.

Musculoskeletal ultrasound (US) now thrives as an established imaging modality for the investigation and management of chronic inflammatory arthritis. We summarize here results of the Outcome Measures in Rheumatology (OMERACT) US working group (WG) projects of the last 2 years. These results were reported at the OMERACT 12 meeting at the plenary session and discussed during breakout sessions. Topics included standardization of US use in rheumatic disease over the last decade and its contribution to understanding musculoskeletal diseases. This is the first update report of WG activities in validating US as an outcome measure in musculoskeletal inflammatory and degenerative diseases, including pediatric arthritis, since the OMERACT 11 meeting.

Objective To study the impacts of 1) the delay from the onset of symptoms to the institution of disease-modifying antirheumatic drug (DMARD) therapy, 2) two treatment strategies (treatment with a combination of DMARDs or with a single drug), and 3) the presence of HLA–DRB1 alleles (shared epitope) on the prediction of disease remission after 2 years in patients with early rheumatoid arthritis (RA). Methods In the FIN-RACo (FINnish Rheumatoid Arthritis Combination therapy) trial, 195 patients with recent-onset RA (median duration 6 months) were randomly assigned to receive either 1) a combination of DMARDs (sulfasalazine, methotrexate, hydroxychloroquine, and prednisolone) or 2) a single DMARD with or without prednisolone. The presence of a shared epitope was tested for in 165 of the 178 patients completing the study. The additional variables of age, sex, presence of rheumatoid factor, number of fulfilled American College of Rheumatology criteria for the classification of RA, and length of delay from onset of symptoms to institution of therapy were entered into a logistic regression model to determine the significant predictors for remission at 2 years. Results The delay to therapy (cut point of 4 months) was the only significant predictor for remission in patients treated using the single-DMARD strategy, while no variable was a significant predictor for remission in those treated using the combination-DMARD strategy. The frequency of achieving remission in the combination-DMARD group after 2 years was similar in patients with short (0–4 months) and long (>4 months) delay periods (11 of 26 patients and 22 of 53 patients, respectively [∼42% in each group]), while the corresponding frequencies in the single-DMARD group were 8 of 23 patients (35%) and 7 of 63 patients (11%) (P = 0.021). The presence of a shared epitope was not related to the induction of remission. Conclusion The delay of a few months from the onset of symptoms to institution of therapy decreases the ability of the traditional single-drug strategy to induce remission in early RA.

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.

Background The short term outcomes of remission-targeted treatments of rheumatoid arthritis (RA) are well established, but the long-term success of such strategies is less clear, as is the role of initial add on biologics. Objectives To assess the evolution of clinical and radiograpich outcomes over 10 years in patients with early RA treated with initial remission-targeted combination-DMARD therapy and additional infliximab or placebo infusions for the first six months Methods Ninety-nine patients with early, DMARD-naive RA were treated with a triple combination of DMARDs, starting with methotrexate (max 25mg/week), sulfasalazine (max 2g/day), hydroxychloroquine (35mg/kg/week), and with prednisolone (7.5mg/day), and randomized to double-blindly receive either infliximab (3mg/kg; FIN-RACo+INFL) or placebo (FIN-RACo+PLA) infusions during the first 6 months. After 2 years the treatment strategies became unrestricted, but the treatment goal was strict ACR remission. At 10 years the clinical and radiographic outcomes were assessed using the intention-to-treat principal. Results Ninety patients (91%) were followed after 2 years, 43 in the FIN-RACo+INFL and 47 in the FIN-RACo+PLA group. At 10 years, the respective proportions of patients in strict ACR and in DAS28 remissions in the FIN-RACo+INFL and FIN-RACo+PLA groups were 48% and 38% [p=0.37 (NNT=10)], and 82% and 72% [p=0.30 (NNT=11)] (Figure 1). The radiographic progression remained slow in most of the patients up till 10 years, the mean (SD) total Sharp van der Hejde score (TSS) was 9.8 (14.8) in the FIN-RACo+INFL and 7.3 (8.1) in the FIN-RACo+PLA group (p=0.34). Only 15% of the patients had TSS>20, and 22% had TSS 0. By ten years, 26% of the FIN-RACo+INFL group patients and 30% of the FIN-RACo+PLA group patients were using biologics (p=0.74). After 5 years, 56% of the patients were at least sporadically using prednisolone, the mean (SD) daily dose was 1.8 (1.6) mg in the FIN-RACo+INFL group and PLA 1.6 (1.4) mg in the FIN-RACo+PLA group. Conclusions In early RA, excellent results can be maintained up till 10 years in most patients treated with initial combination DMARDs and targeted treatment strategy. Adding initial infliximab for 6 months does not improve these outcomes. Acknowledgement The NEO-RACo Trial Group. Disclosure of Interest V. Rantalaiho Grant/research support from: Orion-Farmos Research Foundation, Competitive Research Funding of Tampere University Hospital, T. Sandstrom: None declared, J. Koski: None declared, H. Kautiainen: None declared, M. Leirisalo-Repo Grant/research support from: Helsinki University Central Hospital Research Funds, Finska Lakaresallskapet, Liv och Halsa

Background Blood flow in small vessels of synovial membrane in inflamed joints is characterized by slow-flow. The ability to detect this flow with Doppler ultrasound (US) is influenced by the quality of the US unit, Doppler modality and the Doppler settings. The standard Doppler settings provided by manufacturers of US units have previously been shown not to be optimal for the detection of this slow flow. However, significant improvement of Doppler sensitivity is possible. 1 Objectives The purpose of the study was to investigate how factory Doppler settings (FS) on a high-end US unit could be improved with respect to Doppler sensitivity by ultrasonographers who had just received lectures on optimizing Doppler settings. Secondly, how scoring and quantification of Doppler activity were affected by more sensitive Doppler settings. Methods During an US course arranged as part of targeted ultrasound initiative (TUI) in Helsinki, participants were taught on Doppler settings and how to optimize these. The Doppler settings were adjusted by participants for increased Doppler sensitivity as suggested by Torp-Pedersen et al. 2 A General Electric LOGIQ-E9 ultrasound unit with a 6–15 MHz linear array transducer was used. Four rheumatoid arthritis (RA) patients with a clinically active wrist joint were examined with US by four groups of course participants. US was done using both the FS for superficial musculoskeletal US and the optimized setting (OS). Findings of each joint was scored semi-quantitatively (0–3) and for the maximum colour fraction (CF) using four seconds video clip. CF was calculated using the US unit9s software for quantitative analysis based on a drawn region of interest (ROI). Results All groups were capable of adjusting FS to a more sensitive Doppler setting as suggested in the preceding lectures. The median Doppler score for the four wrist joints were 1 (range: 0–2) on FS and 2 (1–2) on OS. In 12/16 evaluations the Doppler score increased by at least one point on OS compared to FS, and were unchanged in the remaining. In 5/16 evaluations (three patients) the score changed from 0 (normal) to a score of 1 or 2 using OS. The mean CF was 0.021 (range: 0–0.093) on FS and 0.082 (0.008–0.20) on OS (p=0.001; Wilcoxon signed rank test). No significant difference was observed in the area of the ROI (mean: 45 and 44 mm 2 on FS and OS, respectively). Conclusions Optimization of Doppler settings for increased sensitivity for slow flow in synovial tissue of RA wrist joints is possible after proper instruction. An optimized Doppler setting led to significantly higher scores and CF in the examined wrist joints and in some patients synovial Doppler activity was observed only with an optimized setting. Consequently, using FS could result in active joint inflammation being missed or underestimated by the examiner. This small study demonstrates that knowledge on optimizing Doppler settings can be learned in workshops and highlights the importance of knowledge on how to improve Doppler sensitivity wherever US is used in clinical practice. References Torp-Pedersen S, et al. Arthritis Rheumatol. 2015;67:386–95 Torp-Pedersen S, Terslev L. Ann Rheum Dis. 2008;67:143–49 Disclosure of Interest None declared

Objectives. To document the practice and training opportunities of US-guided arthrocentesis and joint injection (UGAJ) among rheumatologists in the member countries of the European League Against Rheumatism (EULAR). Methods. An English-language questionnaire, containing questions on demographics, clinical and practical aspects of UGAJ, training options in UGAJ for rheumatologists, UGAJ education in the rheumatology training curriculum and other structured education programmes in UGAJ was sent to three different groups: (i) all national rheumatology societies of EULAR; (ii) all national societies of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB); and (iii) 22 senior rheumatologists involved in EULAR musculoskeletal US training from 14 European countries, who were also asked to circulate the questionnaire among relevant colleagues. Results. Thirty-three (75%) of 44 countries responded to the questionnaire (61.3% of national rheumatology societies, 25% of the national US societies and 100% of expert ultrasonographers). In the majority of countries (85%) 80%) rate of rheumatologists performing conventional joint injection in most of the surveyed countries. The reported variations in practice and the lack of available structured training programmes for trainees in most countries indicates the need for standardization in areas including training guidelines

Objective. To document the current state of musculoskeletal US (MSUS) training and extent of implementation among rheumatologists in the member countries of EULAR. Methods. An English-language questionnaire, divided into five sections (demographics, clinical use of MSUS, overall MSUS training for rheumatologists, MSUS education in the rheumatology training curriculum and education in MSUS offered by the national rheumatology society) was sent by e-mail to three different groups: (i) all national rheumatology societies of EULAR; (ii) all national societies of the European Federation of Societies for Ultrasound in Medicine and Biology; and (iii) 19 senior rheumatologists involved in MSUS training from 14 European countries. Results. Thirty-one (70.5%) out of 44 countries responded to the questionnaire (59.1% of national rheumatology societies, 34.5% of the national US societies and 100% of expert ultrasonographers). Rheumatology was listed among medical specialities that mainly perform MSUS in 20 (64.5%) countries; however, in most [19 (63.3%)] countries

Objective To produce educational guidelines for the conduct, content and format of theoretical and practical teaching at EULAR musculoskeletal ultrasound (MSUS) Teaching the Teachers (TTT) Courses. Methods A Delphi-based procedure with 24 recommendations covering five main areas (Duration and place of the course; Faculty members; Content of the course; Evaluation of the teaching skills; TTT competency assessment) was distributed among a group of experts involved in MSUS teaching, in addition to an advisory educational expert being present. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%. Results 21 of 24 invited participants responded to the first Delphi questionnaire (88% response rate). All 21 participants also responded to the second round. Agreement on 19 statements was obtained after two rounds. Conclusions This project has led to the development of guidelines for the conduct, content and format of teaching at the EULAR MSUS TTT Courses that are organised annually, with the aim of training future teachers of EULAR MSUS Courses, EULAR Endorsed MSUS Courses, as well as national and local MSUS Courses. The presented work gives indications on how to homogenise the teaching at the MSUS TTT Courses, thus resolving current discrepancies in the field.

Objective: To evaluate the interobserver reliability among 14 experts in musculoskeletal ultrasonography (US) and to determine the overall agreement about the US results compared with magnetic resonance imaging (MRI), which served as the imaging "gold standard". Methods: The clinically dominant joint regions (shoulder, knee, ankle/toe, wrist/finger) of four patients with inflammatory rheumatic diseases were ultrasonographically examined by 14 experts. US results were compared with MRI. Overall agreements, sensitivities, specificities, and interobserver reliabilities were assessed. Results: Taking an agreement in US examination of 10 out of 14 experts into account, the overall κ for all examined joints was 0.76. Calculations for each joint region showed high κ values for the knee (1), moderate values for the shoulder (0.76) and hand/finger (0.59), and low agreement for ankle/toe joints (0.28). κ Values for bone lesions, bursitis, and tendon tears were high (κ = 1). Relatively good agreement for most US findings, compared with MRI, was found for the shoulder (overall agreement 81%, sensitivity 76%, specificity 89%) and knee joint (overall agreement 88%, sensitivity 91%, specificity 88%). Sensitivities were lower for wrist/finger (overall agreement 73%, sensitivity 66%, specificity 88%) and ankle/toe joints (overall agreement 82%, sensitivity 61%, specificity 92%). Conclusion: Interobserver reliabilities, sensitivities, and specificities in comparison with MRI were moderate to good. Further standardisation of US scanning techniques and definitions of different pathological US lesions are necessary to increase the interobserver agreement in musculoskeletal US.

Objective: To describe a new method for taking a synovial biopsy specimen under ultrasound guidance using portal and forceps. Methods: Percutaneous ultrasound guided biopsy was performed for 37 patients with mono- or polyarthritis as outpatients. A portal to a planned area was built using a needle, guiding wire, and dilators, through which forceps could be inserted and samples taken. Biopsy samples were taken from small and large joints, bursae, and tendon sheaths. Results: Representative synovial tissue in adequate amounts for histopathological evaluation was obtained in 33/37 cases—a success rate of 89%. The biopsy procedures were well tolerated, but one complication of skin infection was encountered. Conclusion: The new method of synovium biopsy under ultrasound guidance using sheath introducer set and flexible forceps can be performed on most joints and even bursae and tendon sheaths. The method gives sufficient samples for clinical work in most cases, but further work is needed before accepting this promising technique for scientific purposes.

To the Editor: It is possible to examine the inflammation of a joint, bursa, or tendon area with ultrasonography (US) using greyscale or Doppler imaging1. The detection of perfusion in synovium is a relatively new phenomenon in rheumatology and the detection of a Doppler signal in the synovium is also thought to reflect the inflammatory state2. Rheumatoid synovium is imaged by using color Doppler or power Doppler modes. The latter is thought to be better suited for depicting slow flows3, although there is an article in the literature showing no big difference between these modes4. The aim of this report is to consider what a positive or negative power Doppler signal in the synovium means, especially in terms of histological data. And as well, to raise a question: have we thought too much of anatomy, i.e., the number of vessels (angiogenesis) in Doppler imaging, instead of explaining the existence or absence of Doppler signal with changes of flow (perfusion) in healthy and diseased synovium? In the rheumatoid synovium the thickness of synovial lining hyperplasia, number of vessels, and stage of inflammation of the synovium correlate positively with each other, and the number of vessels is increased5. The question is whether the angiogenesis of the synovitis is the cause or consequence (“chicken or egg”)6. Another study with 44 synovial biopsies in patients with inflammatory joint diseases also showed that the number of vessels correlated positively with the inflammatory state of the synovium r = 0.629, p < 0.01; this statistic was not shown in the original report)7 … Address correspondence to Dr. Koski; E-mail: f.koski{at}fimnet.fi

Fifty consecutive patients with RA and clinical wrist synovitis were randomly allocated to either receive an injection of glucocorticoid into the radiocarpal joint or have the same amount of drug divided into the radiocarpal and midcarpal joints. Inferior radioulnar joint synovitis was treated with extra steroid injection only in the latter group. Patient's and doctor's assessments as well as ultrasonography improved significantly at month 3 in both groups. A statistical difference between the groups was found in the midcarpal joint measurement favouring the extra midcarpal injection. Ten wrists (20%) were normal when assessed with ultrasound at month 3 while 34 wrists (68%) were normal on clinical assessment.

Objectives To investigate the diagnostic performance of non-invasive knee ultrasonography (US) to detect degenerative changes of articular cartilage using arthroscopic grading as the gold standard. Methods 40 adult patients referred to a knee arthroscopy because of knee pain were randomly selected for the study. Before the arthroscopy, knee US was performed and cartilage surfaces at medial and lateral femoral condyles as well as at intercondylar notch area (sulcus) were semi-quantitatively graded from US. Ultrasonographic grading was compared with the arthroscopic Noyes’ grading for cartilage degeneration. Results Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic odds ratio for detecting arthroscopic cartilage changes in US varied between 52-83%, 50-100%, 88-100%, 24-46%, and 5.0-13.0, respectively, depending on the site. Correlation of severity of cartilage changes (grades) between US and arthroscopy varied from insignificant to significant depending on the site: at the sulcus area the correlation was highest ( r s =0.593, p