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Resumen Introduccion El compromiso de la articulacion coxofemoral en la artritis reumatoide se asocia a discapacidad y menor calidad de vida. En la actualidad no existen estudios que evaluen sus alteraciones en etapas subclinicas. Objetivo Determinar la prevalencia del compromiso subclinico de cadera mediante el uso del ultrasonido. Material y metodos Estudio descriptivo de corte transversal, enfocado en pacientes con diagnostico establecido de artritis reumatoide, segun los criterios clasificatorios de la EULAR/ACR 2010, que presentaron o no dolor en la articulacion coxofemoral durante el examen fisico, comparados con individuos sanos. Se investigo la presencia de distension de la capsula articular, bursitis del iliopsoas, erosiones, osteofitos, remodelacion articular y senal Doppler de poder. Las imagenes fueron interpretadas por un reumatologo experto en US, cegado a las variables clinicas, demograficas y de laboratorio. Resultados Se evaluaron en total 234 caderas; 37 (31,6%) pacientes con artritis reumatoide sintomaticos de la cadera, 40 (34,1%) pacientes con artritis reumatoide subclinica y 40 (34,1%) sujetos sanos. La prevalencia de sinovitis de la capsula articular fue del 48,6% para los pacientes con artritis reumatoide sintomatica, del 20% para los pacientes con artritis reumatoide subclinica y del 15% para los sujetos sanos. El grupo de pacientes con artritis reumatoide subclinica presento una mayor frecuencia de osteofitos y remodelacion articular. Conclusiones Se confirmo el valor del ultrasonido en el diagnostico subclinico de la patologia inflamatoria de la articulacion coxofemoral. No se evidenciaron asociaciones significativas entre los hallazgos del US con la actividad de la enfermedad, ni con los valores de estudios de laboratorio.

Introduction The NLR family pyrin domain containing 3 (NLRP3) signaling pathway has an important role in inflammation mediated by monosodium urate crystals in gout, and the characterization of single nucleotide polymorphisms (SNPs) have helped to recognize disease susceptibility. Objective The aim of this review is to provide an overview of the potential role of the inflammasome gene SNPs as a susceptibility factor for gout, discussing the current evidence available. Methods This review analyzes the relevant literature in the field of inflammasome SNPs and gout published in the last 10 years. The systematic research was performed in 16 articles, including both the SNPs associated and those not associated with gout, with the goal to have a complete overview. Results Sixty-nine SNPs from 10 different genes have been reported in the literature. Of these, 13 SNPs present association with gout susceptibility in different populations, while 56 have been established as not being associated with the disease. Conclusions This review is a summary of the potential role of inflammasome gene SNPs and their association with gout risk, all of them related with NLRP3 inflammasome signaling, suggesting these polymorphisms are susceptibility candidates and genetic markers for gout. From the 69 SNPs analyzed in the literature, 13 of them have been associated with gout as follows: NLRP3 (rs3806268 and rs10754558), CARD8 (rs2043211), TLR4 (rs2149356), CD14 (rs2569190), IL-1β (rs1143623), P2RX7 (rs2230911, rs1653624, rs7958316 and rs17525809) and PPARGC1B (rs45520937, rs10491360 and rs7712296) in different populations.

Background: The management of pain in patients with rheumatoid arthritis (RA) is a complex subject due to the autoimmune nature of the pathology. Studies have shown that chemical mediators play a fundamental role in the determination, susceptibility and modulation of pain at different levels of the central and peripheral nervous system, resulting in interesting novel molecular targets to mitigate pain in patients with RA. However, due to the complexity of pain physiology in RA cand the many chemical mediators, the results of several studies are controversial. Objective: The aim of this study was to identify the chemical mediators that are able to modulate pain in RA. Method: In this review, a search was conducted on PubMed, ProQuest, EBSCO, and the Science Citation index for studies that evaluated the expression of chemical mediators on the modulation of pain in RA. Results: Few studies have highlighted the importance of the expression of some chemical mediators that modulate pain in patients with rheumatoid arthritis. The expression of TRPV1, ASIC-3, and TDV8 encode ionic channels in RA and modulates pain, likewise, the transcription factors in RA, such as TNFα, TGF-β1, IL-6, IL-10, IFN-γ, IL-1b, mTOR, p21, caspase 3, EDNRB, CGRPCALCB, CGRP-CALCA, and TAC1 are also directly involved in pain perception. Conclusion: The expression of all chemical mediators is directly related to RA and the modulation of pain by a complex intra and extracellular signaling pathway, however, transcription factors are involved in modulating acute pain, while the ionic channels are involved in chronic pain in RA.

ObjectivesThis study aimed to determine the prevalence of ultrasound-detected tendon abnormalities in healthy subjects (HS) across the age range.MethodsAdult HS (age 18–80 years) were recruited in 23 international Outcome Measures in Rheumatology ultrasound centres and were clinically assessed to exclude inflammatory diseases or overt osteoarthritis before undergoing a bilateral ultrasound examination of digit flexors (DFs) 1–5 and extensor carpi ulnaris (ECU) tendons to detect the presence of tenosynovial hypertrophy (TSH), tenosynovial power Doppler (TPD) and tenosynovial effusion (TEF), usually considered ultrasound signs of inflammatory diseases. A comparison cohort of patients with rheumatoid arthritis (RA) was taken from the Birmingham Early Arthritis early arthritis inception cohort.Results939 HS and 144 patients with RA were included. The majority of HS (85%) had grade 0 for TSH, TPD and TEF in all DF and ECU tendons examined. There was a statistically significant difference in the proportion of TSH and TPD involvement between HS and subjects with RA (HS vs RA pConclusionsUltrasound-detected TSH and TPD abnormalities are rare in HS and can be regarded as markers of active inflammatory disease, especially in newly presenting RA.

Cytokines like IL-6, TNF-α, and IL-1β are important mediators of inflammation in many inflammatory diseases, as well as in cellular processes like cell proliferation and cell adhesion. Finding new molecules that decrease cell proliferation, adhesion (inflammatory infiltrate), and pro-inflammatory cytokine release could help in the treatment of many inflammatory diseases. The naturally derived poly(gallic acid) (PGAL), produced enzymatically from gallic acid in aqueous medium, is a non-toxic, thermostable multiradical polyanion that is antioxidant and has potential biomedical uses. Experimental evidence has demonstrated that PGAL reduces pro-inflammatory cytokines, which are the target of some inflammatory diseases. PGAL decreased IL-6, TNF-α, and IL-1β production in human monocytes exposed to PMA without affecting cell viability. Additionally, PGAL reduced cell proliferation by affecting the transition from the S phase to the G2 phase of the cell cycle. Cell adhesion experiments showed that PMA-induced cell adhesion was diminished with the presence of PGAL, particularly at a concentration of 200 μg/mL. These properties of PGAL show a potential use for treating inflammatory diseases, such as psoriasis or arthritis.

Rheumatoid Arthritis (RA) is an autoimmune disease with unknown etiology and a global incidence around 1%, a positive family history increases the risk of RA roughly three to five times. Pain is one of the first symptoms to appear in this disease. MicroRNAs (miRNAs) belong to the class of small non-coding RNAs; they regulate multiple cellular processes including embryonic development, cellular proliferation, differentiation and apoptosis among others. A great deal of evidence points to the employment of miRNAs as therapeutic targets and biomarkers for several pathologies. The main objective of this Review is to assess how miRNAs participate in the pathogenesis of RA. Two advanced searches were conducted in databases, one using "micro-RNA" and "rheumatoid arthritis" as key words, and another one with "micro-RNA", "pain" and "nociception". In this Review, we describe how six miRNAs: miR-16-5p, miR-23b-3b, miR-124-3p, miR-146a-5p, miR-155-5p and miR-223-3p, involved in the modulation and transmission of the nociceptive input are unregulated in RA patients. Key molecular pathways involved in nociception, inflammation and autoimmune responses, are regulated by these miRNAs; the NF-κB, TNF-α, interleukins and TLR4. By means of gene repression, the miRNAs here described modulate the nociceptive process as well as the autoimmune response that characterize this disease.

Ultrasound (US) is a recognized imaging modality for the assessment of gout. Recently it is being explored for its potential role in the evaluation of subjects with asymptomatic hyperuricemia (AH). Preliminary reports demonstrated the presence of monosodium urate (MSU)-crystal deposits including aggregates, double contour sign and/or tophi in both intra-articular and periarticular tissues of AH individuals. Although these results are exciting, the value and potential application of US in AH remain to be clearly delineated. In this systematic literature review, we aim to summarise the recent publications regarding the role of US in the assessment of AH. We analyzed possible application of US in the daily clinical practice and its future clinical and research potential in the evaluation of AH individuals.

To investigate the potential role of US in the detection of ILD in a cohort of patients with RA.Patients with diagnosis of RA were consecutively enrolled. All patients underwent pulmonary examination, laboratory data, DLCO measure, chest HRCT and radiographs, and US examination. A healthy group was included as control group. US was performed according the 14-intercostal space scanning protocol using the following semiquantitative scale [0=normal (≤5 B-lines); 1=slight (≥6 and ≤15 B-lines); 2=moderate, (≤16 and ≥30 B-lines); 3=severe (≥30 B-lines)].A total of 74 RA patients and 74 healthy controls were included. Thirty of 74 patients (40.5%) showed US signs of ILD with respect to the healthy controls (3 subjects, 4.1%) (P0.001); whereas HRCT showed ILD in 27 (36.4%) of 74 patients. Among the 30 patients that showed US findings of ILD, 17 (56.6%) were asymptomatic from respiratory view-point. The sensitivity and specificity of US were 92% and 89% respectively. A positive correlation between US and HRCT findings were found (P0.001) whereas no correlation was found with chest radiographs and DLCO findings. Positive association between US findings and DAS28-ESR, anti-CCP and RF (P0.01 for each respectively) was found. Feasibility, represented by the mean time spent to perform the pulmonary US assessment was 7.8minutes (±SD 1.2, range 6 to 10minutes).Our results support the potential of US in detect accurately ILD in patients with RA and provide a rationale to consider it as a friendly screening tool to be implemented in early phases of the disease.

Nailfold capillaroscopy (NFC) has gained remarkable interest among rheumatologists because of its utility in both clinical practice and research activity. Nevertheless, there has been scarce attention on its potential in other rheumatic disorders such as vasculitis. We perform a systematic review of literature on NFC in noninfectious vasculitides, with the aim to provide an overview of the main NFC changes described, to discuss the current evidence supporting its clinical impact and applications in daily practice and to provide future research fields.

Objective To assess potential associations among serum cytokines and microRNA (miR) levels with ultrasound (US) findings suggestive of urate deposits in chronic asymptomatic hyperuricemia and gout. Methods All participants underwent musculoskeletal US and measurements of serum interleukin-1β (IL-1β), IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, IL-13, interferon-γ, tumor necrosis factor, monocyte chemoattractant protein 1, and epithelial neutrophil-activating peptide 78, as well as miR-146a, miR-155, and miR-223 levels. Results Thirty individuals with asymptomatic hyperuricemia, 31 normouricemic controls, and 30 patients with gout were included. The frequency of synovitis and double contour sign using US was similar between asymptomatic hyperuricemia (67% and 27%, respectively) and patients with gout (77% and 27%, respectively), and each had a higher frequency than controls (45% and 0%, respectively). Serum IL-6 and IL-8 levels were similar between patients with asymptomatic hyperuricemia (mean ± SD 69.7 ± 73.4 and 18.5 ± 25.6 pg/ml, respectively) and gout (mean ± SD 75.8 ± 47.6 and 24.4 ± 31.7 pg/ml, respectively), and higher than controls (mean ± SD 28.2 ± 17.6 and 7.4 ± 6.0 pg/ml, respectively). A similar distribution was observed for miR-155 levels in asymptomatic hyperuricemia, patients with gout, and controls (mean ± SD 0.22 ± 0.18, 0.20 ± 0.14, and 0.08 ± 0.04, respectively). Associations between morphostructural abnormalities suggestive of urate deposits (regardless of clinical diagnosis) and serum markers were assessed. Subjects with urate deposits had higher IL-6 (257.2 versus 47.0 pg/ml; P = 0.005), IL-8 (73.2 versus 12.0 pg/ml; P = 0.026), and miR-155 (0.21 versus 0.16; P = 0.015) levels than those without deposition findings. Conclusion In individuals with chronic asymptomatic hyperuricemia, the presence of synovitis and double contour sign by US may represent a subclinical manifestation of monosodium urate crystal nucleation, capable of triggering inflammatory pathways (IL-6 and IL-8) and mechanisms of intercellular communication (miR-155), similar to what is observed in patients with gout.

Objective Dactylitis—long considered a hallmark clinical feature of psoriatic arthritis (PsA)—occurs in 16–49% of patients with PsA. In this review, we discuss the pathology of dactylitis in PsA and clinical and imaging tools used to diagnose and monitor dactylitis. Methods PubMed literature searches were conducted using the terms psoriatic arthritis, dactylitis, pathology, imaging, ultrasound, magnetic resonance imaging, clinical, and indices. Articles were deemed relevant if they provided insight into the pathology, diagnosis, and/or monitoring of dactylitis in PsA, or if they discussed clinical or imaging indices used to assess dactylitis. Results Dactylitis in PsA often occurs asymmetrically, involves the feet more than the hands, and affects multiple digits simultaneously. Although dactylitis can be assessed clinically, imaging (radiography, ultrasound, magnetic resonance imaging, and bone scintigraphy) has provided key insights by documenting the various anatomic targets affected. Although inflammation can occur in most of the digital compartments, the nail has not been as well studied in dactylitic digits. Outcome measures for dactylitis range from dichotomous documentation to the Leeds dactylometer. Imaging outcome tools utilizing magnetic resonance imaging or ultrasound are under development. Conclusion Dactylitis, which is associated with more erosive forms of PsA, is often the inaugural feature of PsA and may be the only feature for months to years. Early diagnosis and treatment of PsA favors better outcomes, possibly mitigating radiographic progression and destructive changes. Ultrasound and magnetic resonance imaging are useful tools that have not only shed light on the diverse tissues affected in dactylitis but can also be used to document ongoing inflammation. Ultrasound imaging dactylitis scores are being developed that will assist in diagnosing and documenting which compartments optimally respond to various treatment modalities.

ObjectiveTo evaluate the discriminatory ability of ultrasound in calcium pyrophosphate deposition disease (CPPD), using microscopic analysis of menisci and knee hyaline cartilage (HC) as reference standard.MethodsConsecutive patients scheduled for knee replacement surgery, due to osteoarthritis (OA), were enrolled. Each patient underwent ultrasound examination of the menisci and HC of the knee, scoring each site for presence/absence of CPPD. Ultrasound signs of inflammation (effusion, synovial proliferation and power Doppler) were assessed semiquantitatively (0–3). The menisci and condyles, retrieved during surgery, were examined microscopically by optical light microscopy and by compensated polarised microscopy. CPPs were scored as present/absent in six different samples from the surface and from the internal part of menisci and cartilage. Ultrasound and microscopic analysis were performed by different operators, blinded to each other’s findings.Results11 researchers from seven countries participated in the study. Of 101 enrolled patients, 68 were included in the analysis. In 38 patients, the surgical specimens were insufficient. The overall diagnostic accuracy of ultrasound for CPPD was of 75%—sensitivity of 91% (range 71%–87% in single sites) and specificity of 59% (range 68%–92%). The best sensitivity and specificity were obtained by assessing in combination by ultrasound the medial meniscus and the medial condyle HC (88% and 76%, respectively). No differences were found between patients with and without CPPD regarding ultrasound signs of inflammation.ConclusionUltrasound demonstrated to be an accurate tool for discriminating CPPD. No differences were found between patents with OA alone and CPPD plus OA regarding inflammation.

Ultrasound has been widely explored in systemic sclerosis in the clinical and research settings. Ultrasound allows a non-invasive and ionising radiation-free ‘window’ into this complex disease and is well-suited to repeated examinations. Ultrasound provides novel insights into the pathogenesis and measurement of disease in systemic sclerosis, including early (preclinical) internal organ involvement. The purpose of this review is to describe the role of ultrasound to foster clinical and research advancements in systemic sclerosis relating to (1) musculoskeletal, (2) digital ulcer, (3) lung disease and (4) skin disease. We also highlight unmet needs which much be addressed for ultrasound to assume a central role in systemic sclerosis clinical care and research.

Objective.To provide an overview of the role of lung ultrasound (LUS) in the assessment of interstitial lung disease (ILD) in systemic sclerosis (SSc) and to discuss the state of validation supporting its clinical relevance and application in daily clinical practice.Methods.Original articles published between January 1997 and October 2017 were included. To identify all available studies, a detailed search pertaining to the topic of review was conducted according to guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). A systematic search was performed in PubMed and EMBASE. The quality assessment of retrieved articles was performed according to the Oxford Center for Evidence-based Medicine. The methodological quality of the studies was assessed using the Cochrane Handbook for Systematic Reviews and the Quality Assessment of Diagnostic Accuracy Studies–2 tool.Results.From 300 papers identified, 12 were included for the analysis. LUS passed the filter of face, content validity, and feasibility. However, there is insufficient evidence to support criterion validity, reliability, and sensitivity to change.Conclusion.Despite a great deal of work supporting the potential role of LUS for the assessment of ILD-SSc, much remains to be done before validating its use as an outcome measure in ILD-SSc.

Contains fulltext : 219902.pdf (Publisher’s version ) (Open Access) Capillaroscopy is a non-invasive and safe tool which allows the evaluation of the morphology of the microcirculation. Since its recent incorporation in the 2013 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria for systemic sclerosis together with its assessed role to monitor disease progression, capillaroscopy became a 'mainstream' investigation for rheumatologists. Given its increasing use by a variety of physicians internationally both in daily practice to differentiate primary from secondary Raynaud's phenomenon, as well as in research context to predict disease progression and monitor treatment effects, standardisation in capillaroscopic image acquisition and analysis seems paramount. To step forward to this need, experts in the field of capillaroscopy/microcirculation provide in this very consensus paper their view on image acquisition and analysis, different capillaroscopic techniques, normal and abnormal capillaroscopic characteristics and their meaning, scoring systems and reliability of image acquisition and interpretation.

Introduction and aim. Obesity is a worldwide epidemic problem, described as a risk factor for hepatic diseases, such as non-alcoholic fatty liver disease and other pathologies related to development of cholesterol crystals and cholesterol gallbladder stones. It has been reported that cholesterol overload may cause hepatic damage; however, little is known about the effects of an acute hypercholesterolemic diet on the gallbladder. The aim of this manuscript was to evaluate the impact of a cholesterol-rich diet on the gallbladder. Material and methods. The study included ten eight-week-old C57BL6 male mice, which were divided into two study groups and fed different diets for 48 h: a hypercholesterolemic diet and a balanced Chow diet. After 48 h, the mice were analyzed by US with a Siemens Acuson Antares equipment. Mice were subsequently sacrificed to carry out a cholesterol analysis with a Refloton System (Roche), a crystal analysis with a Carl Zeiss microscope with polarized light, and a histological analysis with Hematoxylin-eosin staining. Results. The hypercholesterolemic diet induced an increase in gallbladder size and total cholesterol content in the bile, along with important histological changes. Conclusion. Cholesterol overloads not only trigger hepatic damage, but also affect the gallbladder significantly.

Objective There are different imaging techniques to assess the parotid glands (i.e., sialography, salivary gland scintigraphy) in patients with Sjogren syndrome (SS). However, their use is limited by the invasive character or high cost. Ultrasound (US) is gaining interest by rheumatologists as a complementary diagnostic tool for SS. To date, there is an increasing body of evidence supporting its sensitivity in the assessment of salivary glands in SS. The aim of our study was to analyze the potential role of US as a diagnostic and prognostic tool in SS and to discuss existing evidence to support its application use. Methods A systematic search was performed in the electronic database PubMed, using the following search terms: (salivary glands OR parotid glands OR submandibular glands) AND Sjogren's syndrome AND (ultrasonography OR ultrasound OR sonography). Titles, abstracts, and full reports were systematically screened. Results The results of the studies analyzed in this review show encouraging results in terms of accuracy, validity, and diagnostic value, which leads us to believe that in the future US could become the reference imaging tool to assess SS. The studies include a small cohort of patients, and there is no standardized approach in terms of US techniques for the assessment of salivary glands. Conclusions Ultrasound of major salivary glands is a useful tool for diagnosis, prognostic evaluation, and response to treatment in SS. The use of this imaging technology is still under development, and more multicentric studies are needed to validate this tool.

Objectives To provide an overview of the main nailfold capillaroscopy (NFC) changes described in dermatomyositis (DM) and polymyositis (PM) and to discuss the current evidence supporting its clinical relevance and applications in daily practice. Methods All relevant literature in the field of NFC and DM and PM published in the last 30 years has been systematically reviewed. A systematic research was performed in the electronic databases PubMed and EMBASE. Results A total of 540 publications were identified according to the proposed filters and 27 were included for the review. The articles have been critically analyzed with a focus on technical aspects, examined anatomical areas, main pathological capillaroscopy findings ,and the relationship between NFC alterations and critical parameters of DM and PM. Conclusions The overview confirms that NFC is a safe and noninvasive tool able to help the clinician in the diagnosis of DM and PM and to better characterize the phase of disease activity of these patients.

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 Musculoskeletal ultrasound improves the accuracy of detecting the level of disease activity (DA) in RA patients, although its impact on the final treatment decision in a real clinical setting is uncertain. The objectives were to define the percentage of clinical scenarios from an ongoing cohort of RA outpatients in which the German Ultrasound Score on 7 joints (GUS-7) impacted the treatment and to explore if the impact differed between a senior rheumatologist (SR) vs. a trainee (TR). Methods Eighty-five consecutive and randomly selected RA outpatients underwent 170 assessments, 85 each by the SR and the TR. Initially, both physicians (blinded to each other) performed a rheumatic assessment and recommended a preliminary treatment. Then, the patients underwent the GUS-7 evaluation by an experienced rheumatologist blinded to clinical evaluations; selected joints of the clinically dominant hand were assessed by gray-scale and power Doppler (PD). In the final step, the TR and the SR integrated the GUS-7 findings with their previous evaluation and reviewed their recommendations. The patients received the final recommendation from the SR to avoid patient confusion. The study was approved by the Internal Review Board and all the patients signed informed consent. GUS-7 usefulness was separately evaluated by the SR and the TR according to a visual analogue scale (0 = not useful at all, 10 = very useful). Descriptive statistics were used. Results The patients were primarily middle-aged females (91.4%) with (mean ± SD) disease duration of 7.5 ± 3.9 years. The majority of them (69.2% according to TR and 71.8% to SR) were in DAS28-ESR-remission. In 34 of 170 clinical scenarios (20%), the GUS-7 findings modified the final treatment proposal; 24 of these scenarios were determined by the TR vs. 10 by the SR: 70.5% vs. 29.5%, p = 0.01. Treatment changes (increase, decrease and joint injection) were similar between both specialists. As expected, the TR rated the GUS-7 usefulness higher than the SR, particularly in the clinical scenarios where the GUS-7 findings impacted treatment. Conclusions Musculoskeletal ultrasound added to standard rheumatic assessments impacted the treatment proposal in a limited number of patients; the impact was greater in the TR.

Psoriatic arthritis (PsA) is a chronic inflammatory disease that may develop in 5–20% of individuals with psoriasis. Psoriasis (PsO) itself affects about 1 to 3% of the general population, with 10 to 55% of this population having some form of clinical nail involvement. Clinical studies have focused on the morphology of nails to determine the associations between the types of nail changes and the presence or severity of PsA. Imaging modalities have demonstrated that an association exists between the nail bed and matrix moving proximally to the distal phalanx, affecting the synovio-entheseal complex, and ultimately the development of distal interphalangeal (DIP) enthesitis. Ultrasound (US) is a noninvasive, operator-dependent, inexpensive imaging modality that can be easily performed in an outpatient setting. It has emerged and solidified its presence in rheumatology and now making its impact in the field of dermatology. The availability of high-frequency US equipment enables very sensitive visualization of blood flow at the dermal level. We describe the recent applications of US in the evaluation of the nail in both PsO and PsA. Early and late anatomical changes in the psoriatic nail can be assessed by ultrasound using gray-scale mode. Power Doppler (PD) provides the ability to detect increased flow in blood vessels of the nail bed of psoriatic nails as well as monitor its response to therapy. With advances in imaging technology, investigators are looking into factors that may predict the early development of PsA. Several studies have demonstrated that an increase in PD score in the nail bed and distal enthesitis are predictors of disease progression of early PsA. Additional prospective studies assessing the strength of correlation between US findings in the nail bed and matrix, nail clinical scoring systems, magnetic resonance imaging (MRI), and histologic findings are needed in order to better define the value of US in the evaluation of the nail in patients with PsO and PsA as an outcome measure.

This study addresses a topic that was previously unaddressed in the literature: the normal sonographic appearance of the Hoffa’s fat pad (HFP) in young, asymptomatic subjects. The aim of the study is to describe the sonoanatomical features of HFP, including its echostructure, echogenicity, elasticity, and vascularization, in subjects without knee pathology. Knees of healthy subjects were examined with grayscale ultrasound (US) to determine the sonographic characteristics of the HFP. Echogenicity was assessed by pixel intensity quantification. Vascularity was evaluated by color Doppler (CD) US. Elasticity of the adipose tissue was examined by sonoelastography. The absence of HFP pathology was confirmed clinically in all participants and by magnetic resonance imaging in randomly selected participants. Seventy-two knees from 36 subjects were assessed. The HFP presented a characteristic well-defined two-layered echostructure: the superficial adipose tissue was hypoechoic with respect to the nearby patellar tendon and contained septae, whereas the deeper layer was homogeneously hypoechoic and lacked connective tissue septae. Echogenicity differed between the superficial and deeper layers (the deeper layer was brighter), suggesting that the degree of acoustic impedance differed between layers. CD detected blood flow in 55.5% of HFPs. The superficial HFP layer presented greater elasticity than the deeper HFP layer (88.8 vs. 75.3 Kpa; p

Introduction: Ultrasound (US) is a rapidly evolving technique that is gaining increasing success in the assessment of psoriatic arthritis (PsA). Recently, new research avenues have been opened, and these are focused on the potential of US for the assessment of extra musculoskeletal areas such as skin and nails. This permits work on the concept of ‘holistic US assessment of PsA’.Areas covered: Here, we analyze the potential role of US in the global assessment of PsA. Additionally, we provide the current evidence supporting its application in routine clinical practice. Literature was obtained from medical databases including PubMed and Embase.Expert commentary: US can detect not only structural abnormalities but also minimal blood flow changes at the superficial soft tissue level. This makes it a great tool for the global assessment of disease activity in PsA, in which persistently active disease plays a major role in causing anatomical damage and physical functional disability.

Resume Objectif Comparer les benefices a court terme des infiltrations de corticoides realisees « a l’aveugle » versus « sous controle echographique », dans le traitement de la tenosynovite chez les patients atteints d’arthrite chronique et determiner si l’infiltration echoguidee est un geste moins douloureux et si des differences existent en termes de modifications de l’aspect echographique au cours du suivi post-injection. Methodes Ont ete inclus dans cette etude des patients qui presentaient une tenosynovite justifiant un traitement par corticoides injectables. Apres l’evaluation clinique et l’etude echographique prealables, les patients ont ete randomises pour faire l’objet d’une infiltration dite « a l’aveugle » ou d’un geste echoguide. L’efficacite de la procedure avait pour critere l’amelioration des scores Health Assessment Questionnaire (HAQ) et des scores echelle visuelle analogique (EVA) douleur qui incluaient le score EVA douleur procedure, EVA douleur globale et EVA douleur locale, mesures a la 1re et la 4e semaine post-injection. Les observations rapportees durant la surveillance echographique en mode Doppler puissance (DP) et en mode B ont egalement fait l’objet du suivi. Les infiltrations a l’aveugle et echoguidees d’une solution contenant 20 mg d’acetate de methylprednisolone ont ete realisees dans des conditions d’asepsie rigoureuses et conformement aux recommandations locales. Resultats Au total, 114 patients ont ete assignes de maniere aleatoire au groupe des infiltrations a l’aveugle (54 patients) ou celui des infiltrations echoguidees (60 patients). Il n’existait initialement aucune difference significative en termes de sexe, d’âge et de duree de la douleur entre les deux groupes. L’infiltration sous controle echographique s’est averee nettement moins douloureuse que le geste realise a l’aveugle (p = 0,0001). L’analyse de l’aire sous la courbe (ASC) a retrouve une meilleure reponse therapeutique au cours du suivi sur la base des scores HAQ, EVA douleur locale et EVA douleur globale (respectivement p = 0,0001, p = 0,012 et p = 0,0001) dans le groupe des infiltrations echoguidees par rapport au geste realise a l’aveugle. Pendant la duree du suivi, une reduction plus marquee des scores en mode DP a ete observee dans le groupe echoguide compare au groupe a l’aveugle (p = 0,0002) sans qu’il y ait de difference statistique constatee entre les deux gestes en mode B (p = 0,5627). Conclusion Notre etude a mis en evidence l’apport benefique significativement superieur des infiltrations echoguidees par rapport aux gestes realises a l’aveugle dans la prise en charge des tenosynovites douloureuses, comme l’indiquent les meilleurs resultats obtenus a court terme et mesures par les scores fonctionnels, cliniques et echographiques. Ces donnees confirment l’interet des infiltrations echoguidees dans le traitement de la tenosynovite en pratique rhumatologique hospitaliere et/ou privee.

Background 9The OMERACT Ultrasound (US) in calcium pyrophosphate deposition disease (CPPD) sub-task force has been working on the assessment of the utility of US in CPPD since 2014 first creating definitions for CPPD identification and then demonstrating that US is a reliable tool[1]. Objectives Objective of this study is to assess the diagnostic accuracy of US in CPPD Methods This is a multicentre international diagnostic accuracy study involving 17 centres from 9 countries. We enrolled in this study consecutive patients waiting to undergo knee replacement surgery due to severe osteoarthritis. Each patient underwent US examination of the knee, focusing on the menisci and the hyaline cartilage, the day prior to surgery, scoring each site according to the presence/absence of CPP as defined by OMERACT[1]. After surgery, the menisci and the condyles were collected 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 the structure. All slides were observed under transmitted light microscopy and by compensated polarised microscopy. A dichotomous score was given for the presence/absence of CPP crystals. US and microscopic analysis were performed by blinded operators. Sensitivity and specificity of US were calculated using microscopic findings of the menisci and cartilage as the gold standard. Results These preliminary analyses include 30 patients. The mean age was 71yrs (SD±9.1), 19 (63%) were females. 17 patients were positive at US analysis and 12 at microscopic analysis. Diagnostic accuracy results of US at patient level, are presented in figure 1. Conclusion These preliminary results demonstrate that US is a sensitive exam for identification of CPPD with acceptable specificity. US is the first diagnostic technique with consistent reliability and validity to be applied for non-invasive screening for CPPD in clinical practice. References [1] Filippou G, Scire 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 Dis 2018;:annrheumdis-2017-212542. doi:10.1136/annrheumdis-2017-212542 Disclosure of Interests Georgios Filippou Speakers bureau: Laborest, Abbvie, BMS, Sanofi, Anna Scanu: None declared, Antonella Adinolfi: None declared, Carmela Toscano: None declared, Raquel Largo-Carazo: None declared, Esperanza Naredo Consultant for: Abbvie, Speakers bureau: AbbVie, Roche, Bristol-Myers Squibb, Pfizer, UCB, Lilly, Novartis, Janssen, and Celgene GmbH, 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, Ingrid Moller: None declared, Marwin Gutierrez: None declared, Carlos Pineda: None declared, Denise Clavijo Cornejo: None declared, Hector Garcia: None declared, Victor Ilizaliturri: None declared, Jaime Mendoza Torres: None declared, Raul Pichardo: None declared, Luis Carlos Rodriguez Delgado: None declared, Emilio Filippucci: None declared, Edoardo Cipolletta: None declared, Teodora Serban: None declared, Florentin Ananu Vreju Consultant for: abbvie and novartis, Speakers bureau: abbvie, novartis, pfizer, sandoz, eli lilly, ucb pharma, Gael Mouterde: None declared, Maria-Antonietta d’Agostino: None declared, Marcello Govoni: None declared, Leonardo Punzi Consultant for: BMS, Fidia, Grunenthal, Menarini, Speakers bureau: BMS, Fidia, Grunenthal, Menarini, Nemanja Damjanov Grant/research support from: AbbVie, Pfizer and Roche, Consultant for: Abbvie, Gedeon Richter, Merck, Novartis, Pfizer and Roche., Speakers bureau: Abbvie, Gedeon Richter, Merck, Novartis, Pfizer and Roche., Lene Terslev Speakers bureau: Speakers fee from : Roche, Novartis, Pfizer, MSD, BMS, Celgene, Irene Azzolin: None declared, Giulio Guerrini: None declared, Carlo Alberto Scire: None declared, Annamaria Iagnocco: None declared

Background: Tenosynovitis (TS) is a common, often clinically undetectable finding in Rheumatoid Arthritis (RA). Recent data showed TS on ultrasound (US) has a role in predicting outcome in early disease and flare in clinical remission. However data is limited on US measured TS in healthy subjects (HS), none specifically encompassing the older age range when RA commonly presents. Objectives: This OMERACT study aimed to determine prevalence of US measured tendon abnormalities in HS throughout the age range. Methods: Adult HS without: joint pain (VAS A comparison cohort of DMARD-naive patients with RA (ACR-EULAR 2010 and/or 1987 criteria) at presentation was taken from the Birmingham Early Arthritis (BEACON) inception cohort, who underwent identical tendon US assessment. They were grouped into ≤12 and > 12 weeks from symptom onset. Results: Data from 899 HS and 144 RA patients were included. Prevalence of TSH and particularly PD abnormalities in HS was very low at all ages, and was all grade 1 except in one individual ECU tendon. ECU TSH grade≥1 was more common than DF grade≥1 in the older HS groups, and less common in the 18-39 age group (p=0.011). TSH and PD of grade ≥1 were common in RA patients, with DF PD abnormalities more common in early disease (p=0.02). Conclusion: Low prevalence of TSH or PD abnormalities in tendons of HS even in old age suggests US determined TS will be a robust tool in clinically managing RA. References: [1] Naredo E, D’Agostino MA, et al. Reliability consensus-based US score TS RA. ARD.2013;72(8):1328-34 Disclosure of Interests: Jeanette Trickey: None declared, Ilfita Sahbudin: None declared, Alessandra Bortoluzzi: None declared, Annamaria Iagnocco: None declared, Carlos Pineda: None declared, Cesar Sifuentes-Cantu: None declared, Coziana Ciurtin: None declared, Cristina Reategui Sokolova: None declared, Daniela Fodor: None declared, Ellen-Margrethe Hauge: None declared, Esperanza Naredo Consultant for: Abbvie, Speakers bureau: AbbVie, Roche, Bristol-Myers Squibb, Pfizer, UCB, Lilly, Novartis, Janssen, and Celgene GmbH, Florentin Ananu Vreju Consultant for: abbvie and novartis, Speakers bureau: abbvie, novartis, pfizer, sandoz, eli lilly, ucb pharma, Garifallia Sakellariou: None declared, George Bruyn : None declared, Georgios Filippou Speakers bureau: Laborest, Abbvie, BMS, Sanofi, Giuliana M.C. La Paglia : None declared, Gustavo Leon: None declared, Helen Keen: None declared, Hilde Berner Hammer Grant/research support from: AbbVie, Pfizer and Roche, Paid instructor for: AbbVie, Pfizer, UCB, Novartis, Roche, Speakers bureau: AbbVie, Pfizer, UCB, Novartis, Roche, Ilaria Tinazzi: None declared, Irene Azzolin: None declared, Jacek Flicinski: None declared, James Wilton: None declared, Kei Ikeda: None declared, Lene Terslev Speakers bureau: Speakers fee from : Roche, Novartis, Pfizer, MSD, BMS, Celgene, Mads Ammitzboll-Danielsen: None declared, Mads Nyhuus Bendix Rasch: None declared, Marcin Milchert: None declared, Maria Stoenoiu Grant/research support from: Abbvie, Roche, Wyeth, Marion Kortekaas: None declared, Marwin Gutierrez: None declared, Mihaela Maruseac: None declared, Mohammed A Mortada: None declared, Philippe Carron: None declared, Rositsa Karalilova: None declared, Ruth Wittoek: None declared, Sarah Ohrndorf: None declared, Takeshi Suzuki: None declared, Teodora Serban: None declared, Maria-Antonietta d’Agostino: None declared, Andrew Filer: None declared

Background Interstitial lung disease (ILD) is the most frequent pulmonary impairment in Sjogren’s syndrome (SS). The diagnosis is challenging, as there are not specific tests (i.e. autoantibodies or pulmonary function tests) or symptoms. Chest CT is the gold standard. Semiquantitative visual scores (SQCT) estimate ILD extent, though burdened by relevant intra-, inter-rater variability. Quantitative chest CT (QCT) is a promising method to assess ILD severity Objectives: to verify if QCT assessment could identify SS subjects affected by ILD and to identify those SS patients with an extensive lung disease. Methods: in this multi-center, cross-sectional, and retrospective study, subjects affected by SS and with a chest CT were enrolled. A blind and centralized SQCT assessment was carried out in order to calculate both Goh and Taouli scores. An operator-independent analysis of all CTs with an open-source software (i.e. Horos), provided the QCT indexes. Patients were clustered in cohorts according to ILD extent. Differences in QCT indexes distribution were analyzed using non-parametric tests. Results 102 consecutive SS patients were enrolled. ILD prevalence was 36% (36/102). There was a difference in QCT indexes’ distribution in SS-ILD versus SS without ILD (p 20% (according to Goh score) had QCT indexes statistically different from those with a limited ILD extension (p 0.7; the best QTC index was: tSkew AUC 0.87 (95CI 0.78-0.95), p Conclusion QCT indexes are a serious alternative to visual scorings in ILD related to autoimmune diseases. This innovative tool will open up a potential research area in SS as it appears able to select ILD patients with an extensive lung impairment and likewise a worse prognosis. We are confident that in the next future, QCT will have a pivotal role in the diagnosis, monitoring and treatment pathway of ILD associated to SS. References [1] Silva M, Milanese G, Seletti V, Ariani A, Sverzellati N. Pulmonary quantitative CT imaging in focal and diffuse disease: current research and clinical applications. Br J Radiol2018; 91: 20170644. Disclosure of Interests None declared

Background: Nowadays, rheumatologists face challenges in finding an effective method to classify and treat patients with undifferentiated arthritis (UA). There is a need for new tools that could ensure accurate characterization of inflammatory processes in these patients. Objectives: To investigate if a characterization of UA patients using US may help to fulfill the 2010 ACR/EULAR RA classification criteria in a real-life cohort. Methods: We conducted a cross sectional study in two rheumatology care clinics. Patients not fulfilling the 2010 ACR/EULAR RA criteria were included. On the examination day, all patients underwent a physical examination, radiographs and US. The 7-joint US score (US 7) was adopted to scan all patients. US was performed according to EULAR criteria and interpreted by OMERACT definitions. Greyscale and power Doppler synovitis and tenosynovitis were scored. Bone erosions were also evaluated during the US examination. Results: A total of 204 patients were included. The diagnosis was modified from UA to RA in 86 (42.1%) patients. The greater proportion of synovitis detected by US was the main parameter that allowed changing the diagnosis from UA to RA, and modified the final score of the 2010 ACR/EULAR classification criteria, from a mean (±SD) of 4.6 (0.5), by clinical examination, to 6.5 (0.6) by US. The changes in the score of the 2010 ACR/EULAR classification criteria were from score 4 to score 6 in 6 (7%) patients; from 4 to 7 in 24 (27.9%) patients; from 5 to 6 in 42 (48.8%) patients; from 5 to 7 in 5 (5.8%) patients and from 5 to 8 in 5 (5.8%) patients. In addition to synovitis, a wide range of tenosynovitis and bone erosions were detected by US. Synovitis was more frequently detected in 2ndMCPj followed by 2ndMTPj and 5thMTPj. The tendons of the wrist, 2nd and 3th finger were the most affected. In relation to bone erosions, 2ndMCPj and 5thMTPj where the joints with more proportion of anatomical damage. Conclusion: US demonstrated to be useful to help accurately classify as RA, patients previously diagnosed with UA. Disclosure of Interests: Marwin Gutierrez: None declared, Chiara Bertolazzi: None declared, Edwin Castillo: None declared, Denise Clavijo Cornejo: None declared, Luis Carlos Rodriguez Delgado: None declared, Jaime Mendoza Torres: None declared, Carlos Pineda: None declared, Pedro Santos-Moreno Grant/research support from: Dr Santos has received research grants from Janssen, Abbvie and UCB, Speakers bureau: Dr Santos has received speaker fees from Sanofi, Lilly, Bristol, Pfizer, Abbvie, Janssen and UCB

Background Interstitial lung disease (ILD) evaluation is challenging, given the low sensitivity of X-ray and pulmonary function tests, and limited accessibility and radiation linked to repetitive HRCT. Lung Ultrasound (US) has shown potential in the evaluation of ILD of autoimmune diseases including systemic sclerosis. Objectives To define and asses the reliability of definitions of US-detected findings in ILD. Methods A taskforce (TF) within the OMERACT US WG performed a literature review (LR) to identify US lesions in ILD, a Delphi exercise to define these lesions and a web-based exercise to test the reliability of these definitions by using either intraclass correlation coefficient (ICC) or kappa statistics. Prior to the Delphi exercise all participants received training files and were subsequently asked to provide clips on BL, PLI and normal findings. Based on the results of the LR, which identified B-lines (BL) and pleural line irregularity (PLI) as main US findings in ILD, the Delphi exercise contained statements on US definitions on BL and PLI. After reaching agreement (> 75%) on the above mentioned items, a set of 80 high-quality clips (30 for PLI, 50 for BL), was selected and distributed to the TF members in order to score them (semiquantitatively, 0-2 for PLI and total number for BL) Results The 3 Delphi rounds and the web-based exercise were completed by 24 and 22 sonographers, respectively. Final definitions are reported in Table I. The web-based exercise showed moderate inter-reader reliability for both BL (ICC=0.61) and PLI (kappa=0.69). Table I: definitions of PLI and BL Pleural line irregularity (PLI): a loss of regularity that may be associated with an increase in thickness, focal, diffuse, or nodular B-line (BL): a vertical hyperechoic reverberation artifacts that arise from the pleural line, extend to the bottom of the screen without fading, and move synchronously with lung sliding Conclusion US is a candidate imaging modality to identify and monitor ILD in rheumatic diseases; US consensus based definitions of main US findings were defined and endorsed. Further development is planned for validating US as an outcome measurement instrument for ILD. Disclosure of Interests Andrea Delle Sedie Speakers bureau: Abbvie, UCB, Celgene, MSD, Lene Terslev Speakers bureau: Speakers fee from : Roche, Novartis, Pfizer, MSD, BMS, Celgene, George Bruyn : None declared, Tomas Cazenave: None declared, stavros chrysidis: None declared, Mario Diaz: None declared, Marco Di Carlo: None declared, Marilena Frigato: None declared, Luna Gargani: None declared, Marwin Gutierrez: None declared, ALOJZIJA HOCEVAR: None declared, Annamaria Iagnocco: None declared, Aaron Juche: None declared, Peter Mandl: None declared, Esperanza Naredo Consultant for: Abbvie, Speakers bureau: AbbVie, Roche, Bristol-Myers Squibb, Pfizer, UCB, Lilly, Novartis, Janssen, and Celgene GmbH, Mohammed A Mortada: None declared, Carlos Pineda: None declared, Francesco Porta: None declared, Viviana Ravagnani: None declared, Carlo Alberto Scire: None declared, Teodora Serban: None declared, Kate Smith: None declared, Maria Stoenoiu Grant/research support from: Abbvie, Roche, Wyeth, Marika Tardella: None declared, Karina Torralba: None declared, Richard Wakefield: None declared, Maria-Antonietta d’Agostino: None declared

Background: Accelerated atherosclerosis and the higher risk of developing premature cardiovascular disease are well known in chronic inflammatory rheumatic diseases. Moreover, strong evidence supporting both proatherogenic and protrombotic characteristics of high levels of uric acid have been published. Ultrasound (US) measurement of the carotid intima-media thickness (cIMT) is a non-invasive outcome measure of premature sub-clinical atherosclerosis with a predictive value in terms of vascular events. Objectives: To determine the prevalence of increased cIMT, as sign of pre-clinical atherosclerosis, in patients with gout and asymptomatic hyperuricemia by an automated ultrasound (US) method. Methods: 342 subjects (138 with gout, 105 with asymptomatic hyperuricemia and 99 healthy control subjects) were enrolled. Before the US assessment, all patients underwent a clinical examination aimed to record age, gender, disease duration, smoking, ischemic cardiopathy, comorbidities (including diabetes mellitus, high blood pressure, dyslipidemia, renal insufficiency, obesity), and current therapy. Moreover, ESR, CRP, total cholesterol, HDL-high-density lipoprotein, triglycerides, fasting serum glucose, serum creatinine and uricemia were recorded. Patients with history of myocardial infarction, cerebrovascular events or autoimmune diseases were excluded. US examinations of the IMT at both common carotids were performed by a rheumatologist expert in US, using a linear probe and an automatic method (QIMT) based on the radio-frequency technology. For the IMT, a cut-off point of 0.8 mm was adopted, according Mannheim cIMT Consensus. Results: A total of 684 common carotids were assessed. In 65 (47.10%) out of the 138 patients with gout and 50 (47.62%) out of the 105 patients with asymptomatic hyperuricemia, US detected an increased cIMT and only 9 (0.09%) of the control group patients had an increased cIMT (p=0.0001). The regression analysis found a significant positive correlation between increased cIMT and disease duration in gout group (p=0.001) and between the level of uric acid and increased cIMT in asymptomatic hyperuricemic patients (p=0.009). No significant correlation was found with the other clinical and laboratory parameters. There was a significant difference in cIMT between in gout and control groups (p=0.0001) and between asymptomatic hyperuricemia and control group (p=0.0001). Conclusion: Our results demonstrate that patients with gout and hyperuricemia without clinically evident cardiovascular disease have a high prevalence of atherosclerosis represented by the increased cIMT. Disclosure of Interests: None declared

Contains fulltext : 215793.pdf (Publisher’s version ) (Open Access) OBJECTIVES: This study was designed to propose a simple "Fast Track algorithm" for capillaroscopists of any level of experience to differentiate "scleroderma patterns" from "non-scleroderma patterns" on capillaroscopy and to assess its inter-rater reliability. METHODS: Based on existing definitions to categorise capillaroscopic images as "scleroderma patterns" and taking into account the real life variability of capillaroscopic images described standardly according to the European League Against Rheumatism (EULAR) Study Group on Microcirculation in Rheumatic Diseases, a fast track decision tree, the "Fast Track algorithm" was created by the principal expert (VS) to facilitate swift categorisation of an image as "non-scleroderma pattern (category 1)" or "scleroderma pattern (category 2)". Mean inter-rater reliability between all raters (experts/attendees) of the 8th EULAR course on capillaroscopy in Rheumatic Diseases (Genoa, 2018) and, as external validation, of the 8th European Scleroderma Trials and Research group (EUSTAR) course on systemic sclerosis (SSc) (Nijmegen, 2019) versus the principal expert, as well as reliability between the rater pairs themselves was assessed by mean Cohen's and Light's kappa coefficients. RESULTS: Mean Cohen's kappa was 1/0.96 (95% CI 0.95-0.98) for the 6 experts/135 attendees of the 8th EULAR capillaroscopy course and 1/0.94 (95% CI 0.92-0.96) for the 3 experts/85 attendees of the 8th EUSTAR SSc course. Light's kappa was 1/0.92 at the 8th EULAR capillaroscopy course, and 1/0.87 at the 8th EUSTAR SSc course. CONCLUSION: For the first time, a clinical expert based fast track decision algorithm has been developed to differentiate a "non-scleroderma" from a "scleroderma pattern" on capillaroscopic images, demonstrating excellent reliability when applied by capillaroscopists with varying levels of expertise versus the principal expert and corroborated with external validation.

Background Nowadays, rheumatologists face challenges in finding an effective method to classify and treat patients with undifferentiated arthritis (UA). There is a need for new tools that could ensure accurate characterization of inflammatory processes in these patients. Objective The aim of this study was to investigate if a characterization of UA patients using ultrasound (US) may help to fulfill the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) rheumatoid arthritis (RA) classification criteria in a real-life cohort. Methods We conducted a cross-sectional study in 2 rheumatology care clinics. Patients not fulfilling the 2010 ACR/EULAR RA criteria were included. On the examination day, all patients underwent a physical examination, radiography, and US. The 7-joint US score was adopted to scan all patients. The US was performed according to EULAR criteria and interpreted by Outcome Measures in Rheumatology definitions. Gray-scale and power Doppler synovitis and tenosynovitis were scored. Bone erosions were also evaluated during the US examination. Results A total of 204 patients were included. The diagnosis was modified from UA to RA in 86 patients (42.1%). Also, the final score of the 2010 ACR/EULAR RA classification criteria changed from a mean of 4.6 to 6.5 after the US examination. In addition to synovitis, a wide range of tenosynovitis and bone erosions were detected by US. Synovitis was more frequently detected in second metacarpophalangeal joint followed by second metatarsophalangeal joint (MTPj) and fifth MTPj. The tendons of the wrist and second and third fingers were the most affected. In relation to bone erosions, second metacarpophalangeal joint and fifth MTPj were the joints with more proportion of anatomical damage. Conclusions The US demonstrated to be useful to help accurately classify as RA patients previously diagnosed with UA.

The aim of this work was to produce a consensus-based report for capillaroscopy in rheumatology to be used in daily clinical practice. A written Delphi questionnaire regarding capillaroscopy report was developed from a literature review and expert consensus. The Delphi questionnaire was sent to an international panel including 25 rheumatologists experts in capillaroscopy, asking them to rate their level of agreement or disagreement with each statement. The exercise consisted of three online rounds and a face-to-face (live meeting) that took place in the PANLAR 2018 congress held in Buenos Aires, Argentina. The participants to the first, second, third, and face-to-face round were 22, 21, 21, and 16 rheumatologists, respectively. Fifty-five items were discussed in the first round, 58 in the second, 22 in the third, and 9 in the face-to-face meeting. At the end of the exercise, 46 recommendations for the capillaroscopy report in rheumatology reached a consensus. This is the first consensus-based report in capillaroscopy. It will be useful in daily clinical practice and to address the effort of the standardization in the technique. • The current lack of consensus for the capillaroscopy report makes difficult the interpretation of findings as well as follow-up of rheumatic diseases. • This study produced the first international consensus for the format and content of the naifold capillaroscopy report in rheumatology. • The report is an integral part of the capillaroscopy examination and its use in a homogeneous form can help in the correct interpretation of findings in daily practice.

Objective.The purpose of the ULISSE study was to evaluate the prevalence of clinical and ultrasonographic (US) entheseal involvement in patients with psoriatic arthritis (PsA), psoriasis, and fibromyalgia syndrome (FMS).Methods.In this cross-sectional multicenter study, patients with PsA and psoriasis (not taking systemic therapy) and FMS underwent a clinical evaluation of the entheses, and a B-mode and power Doppler examination of 6 pairs of entheses.Results.The study analyzed 140 patients with PsA, 51 with psoriasis, and 51 with FMS. Clinical and US examinations were performed in 1960 and 1680 entheses in the PsA group, and 714 and 612 entheses both in the psoriasis group and in the FMS group. In both per-patient and per-enthesis evaluation, the frequency of entheseal tenderness was higher in patients with FMS (92% of the patients and 46% of the entheses, compared with 66%/23% in the PsA group and 59%/18% in the psoriasis group). With US examination, signs of entheseal involvement were more frequent in both the per-patient and per-enthesis evaluation in PsA and psoriasis (about 90% of patients in both the PsA and psoriasis groups and 75% of patients in the FMS group had at least 1 site affected, and 54%, 41%, and 27% of the pairs of entheses in, respectively, PsA, psoriasis, and FMS patients showed at least 1 enthesis involved).Conclusion.The ULISSE study indicated that enthesitis is a common feature in patients with PsA, those with psoriasis, and in those with FMS if only clinical examination is used. US entheseal assessment showed findings more consistent with the 3 disorders.

Background: Interstitial lung disease (ILD) is a frequent manifestation of Sjögren's syndrome (SS), an autoimmune disease of salivary and lacrimal glands, and affects approximately 20% of patients. No clinical or serological features appear to be useful to predict its presence, severity or progression, and chest high-resolution computed tomography (CT) remains the gold standard for diagnosis. Semiquantitative CT (SQCT) based on visual assessment (Goh and Taouli scoring) can estimate ILD extent, although it is burdened by relevant intra- and interobserver variability. Quantitative chest CT (QCT) is a promising alternative modality to assess ILD severity. Aim: To determine whether QCT assessment can identify extensive or limited lung disease in patients with SS and ILD. Methods: This multi-center, cross-sectional and retrospective study enrolled patients with SS and a chest CT scan. SQCT assessment was carried out in a blinded and centralized manner to calculate both Goh and Taouli scores. An operator-independent analysis of all CT scans with the open-source software platform Horos was used to evaluate the QCT indices. Patients were classified according to the extent of ILD and differences in QCT index distribution were investigated with non-parametric tests. Results: From a total of 102 consecutive patients with SS, the prevalence of ILD was 35.3% (36/102). There was a statistically significant difference in QCT index distribution between the SS with ILD and SS without ILD groups (p20% (by Goh score) had a QCT index statistically different from those with limited ILD extent (p

Objectives To develop and test the reliability of a new semiquantitative scoring system for the assessment of cartilage changes by ultrasound in a web-based exercise as well as a patient exercise of patients with RA. Methods A taskforce of the Outcome Measures in Rheumatology Ultrasound Working Group performed a systematic literature review on the US assessment of cartilage in RA, followed by a Delphi survey on cartilage changes and a new semiquantitative US scoring system, and finally a web-based exercise as well as a patient exercise. For the web-based exercise, taskforce members scored a dataset of anonymized static images of MCP joints in RA patients and healthy controls, which also contained duplicate images. Subsequently, 12 taskforce members used the same US to score cartilage in MCP and proximal interphalangeal joints of six patients with RA in in a patient reliability exercise. Percentage agreement and prevalence of lesions were calculated, as intrareader reliability was assessed by weighted kappa and interreader reliability by Light’s kappa. Results The three-grade semiquantitative scoring system demonstrated excellent intrareader reliability (kappa: 0.87 and 0.83) in the web-based exercise and the patient exercise, respectively. Interreader reliability was good in the web-based exercise (kappa: 0.64) and moderate (kappa: 0.48) in the patient exercise. Conclusion Our study demonstrates that ultrasound is a reliable tool for evaluating cartilage changes in the MCP joints of patients with RA and supports further development of a new reliable semiquantitative ultrasound scoring system for evaluating cartilage involvement in RA.

OBJECTIVE: The language currently used to describe gout lacks standardisation. The aim of this project was to develop a consensus statement on the labels and definitions used to describe the basic disease elements of gout. METHODS: Experts in gout (n=130) were invited to participate in a Delphi exercise and face-to-face consensus meeting to reach consensus on the labelling and definitions for the basic disease elements of gout. Disease elements and labels in current use were derived from a content analysis of the contemporary medical literature, and the results of this analysis were used for item selection in the Delphi exercise and face-to-face consensus meeting. RESULTS: There were 51 respondents to the Delphi exercise and 30 attendees at the face-to-face meeting. Consensus agreement (≥80%) was achieved for the labels of eight disease elements through the Delphi exercise; the remaining three labels reached consensus agreement through the face-to-face consensus meeting. The agreed labels were: monosodium urate crystals, urate, hyperuric(a)emia, tophus, subcutaneous tophus, gout flare, intercritical gout, chronic gouty arthritis, imaging evidence of monosodium urate crystal deposition, gouty bone erosion and podagra. The face-to-face meeting achieved consensus agreement for the definitions of all 11 elements and a recommendation that the label 'chronic gout' should not be used. CONCLUSION: Consensus agreement was achieved for the labels and definitions of 11 elements representing the fundamental components of gout aetiology, pathophysiology and clinical presentation. The Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) recommends the use of these labels when describing the basic disease elements of gout. This article is protected by copyright. All rights reserved.

ObjectiveThere is a lack of standardisation in the terminology used to describe gout. The aim of this project was to develop a consensus statement describing the recommended nomenclature for disease states of gout.MethodsA content analysis of gout-related articles from rheumatology and general internal medicine journals published over a 5-year period identified potential disease states and the labels commonly assigned to them. Based on these findings, experts in gout were invited to participate in a Delphi exercise and face-to-face consensus meeting to reach agreement on disease state labels and definitions.ResultsThe content analysis identified 13 unique disease states and a total of 63 unique labels. The Delphi exercise (n=76 respondents) and face-to-face meeting (n=35 attendees) established consensus agreement for eight disease state labels and definitions. The agreed labels were as follows: ‘asymptomatic hyperuricaemia’, ‘asymptomatic monosodium urate crystal deposition’, ‘asymptomatic hyperuricaemia with monosodium urate crystal deposition’, ‘gout’, ‘tophaceous gout’, ‘erosive gout’, ‘first gout flare’ and ‘recurrent gout flares’. There was consensus agreement that the label ‘gout’ should be restricted to current or prior clinically evident disease caused by monosodium urate crystal deposition (gout flare, chronic gouty arthritis or subcutaneous tophus).ConclusionConsensus agreement has been established for the labels and definitions of eight gout disease states, including ‘gout’ itself. The Gout, Hyperuricaemia and Crystal-Associated Disease Network recommends the use of these labels when describing disease states of gout in research and clinical practice.

Objective.To evaluate the intraobserver and interobserver reliability of the ultrasonographic (US) assessment of subtalar joint (STJ) synovitis in patients with rheumatoid arthritis (RA).Methods.Following a Delphi process, 12 sonographers conducted an US reliability exercise on 10 RA patients with hindfoot pain. The anteromedial, posteromedial, and posterolateral STJ was assessed using B-mode and power Doppler (PD) techniques according to an agreed US protocol and using a 4-grade semiquantitative grading score for synovitis [synovial hypertrophy (SH) and signal] and a dichotomous score for the presence of joint effusion (JE). Intraobserver and interobserver reliability were computed by Cohen’s and Light’s κ. Weighted κ coefficients with absolute weighting were computed for B-mode and PD signal.Results.Mean weighted Cohen’s κ for SH, PD, and JE were 0.80 (95% CI 0.62–0.98), 0.61 (95% CI 0.48–0.73), and 0.52 (95% CI 0.36–0.67), respectively. Weighted Cohen’s κ for SH, PD, and JE in the anteromedial, posteromedial, and posterolateral STJ were −0.04 to 0.79, 0.42–0.95, and 0.28–0.77; 0.31–1, −0.05 to 0.65, and −0.2 to 0.69; 0.66–1, 0.52–1, and 0.42–0.88, respectively. Weighted Light’s κ for SH was 0.67 (95% CI 0.58–0.74), 0.46 (95% CI 0.35–0.59) for PD, and 0.16 (95% CI 0.08–0.27) for JE. Weighted Light’s κ for SH, PD, and JE were 0.63 (95% CI 0.45–0.82), 0.33 (95% CI 0.19–0.42), and 0.09 (95% CI −0.01 to 0.19), for the anteromedial; 0.49 (95% CI 0.27–0.64), 0.35 (95% CI 0.27–0.4), and 0.04 (95% CI −0.06 to 0.1) for posteromedial; and 0.82 (95% CI 0.75–0.89), 0.66 (95% CI 0.56–0.8), and 0.18 (95% CI 0.04–0.34) for posterolateral STJ, respectively.Conclusion.Using a multisite assessment, US appears to be a reliable tool for assessing synovitis of STJ in RA.

The aim of this study was to evaluate the reliability of the outcome measures in rheumatology (OMERACT) definitions for ultrasound (US) elementary lesions in gout through an image reading exercise. Images from patients with gout (static images and videos) were collected. As an initial step, we carried out a image reading exercise within the experts of the Pan-American League of Associations for Rheumatology (PANLAR) US Study Group (n = 16). The following step consisted in a web-based exercise with the participation of larger number of sonographers (n = 63) from different centers. Images were rated evaluating the presence/absence of any US elementary lesion. Inter- and intra-reader reliabilities were analyzed using kappa coefficients. Participants were stratified according to their level of experience. In the first exercise, inter-reader kappa values were 0.45 for aggregates, 0.57 for tophus, 0.69 for erosions, and 0.90 for double contour (DC). Intra-reader kappa values were 0.86, 0.76, 0.80, and 0.90, respectively. The web-based exercise showed inter-reader kappa values for aggregates, tophus, erosions, and DC of 0.42, 0.49, 0.69, and 0.79, respectively. The intra-reader kappa values were 0.62, 0.69, 0.77, and 0.85, respectively. Reliability was not influenced by the sonographer’s level of experience. The reliability of the new OMERACT US definitions for elementary lesions in gout ranged from moderate to excellent, depending on the type of lesion.

The objective of the present study is to evaluate, by ultrasonography (US), the prevalence in the quadriceps, patellar, and Achilles tendon involvement of gout compared to that of patients with osteoarthritis and asymptomatic marathon runners. This is a multicenter, multinational, transverse cross-sectional, and comparative study comprising 80 patients with the diagnosis of gout according to the American College of Rheumatology (ACR) criteria, compared with two control groups: 35 patients with generalized osteoarthritis according to the ACR criteria and 35 subjects who were healthy marathon runners. Demographics and clinical characteristics, such as age, gender, comorbidity, disease duration, pain at the enthesis in the knee and ankle, frequency of disease exacerbations, uric acid level more than 7.2 mg at the time of evaluation, and type of treatment, were recorded. All participants were examined by ultrasound at the quadriceps, the patellar at its proximal and distal insertion, and the Achilles tendon to detect intra-tendinous tophus or aggregates according to the OMERACT definitions. Descriptive statistics and differences between groups were analyzed by chi-square test. Sensitivity and specificity by US were calculated. The prevalence of intra-tendinous aggregates and tophi in gout was significant compared with the other groups. Both lesions were the most frequent at the distal patellar insertion, followed by the quadriceps, Achilles, and proximal patellar insertion ones. In patients with osteoarthritis (OA), intra-tendinous hyperechoic aggregates were observed in 20 % of quadriceps tendons and in 11 % of patellar tendons at its proximal insertion, while in the healthy marathon runner group, the Achilles tendon had this kind of lesion in 17 % of the subjects. Neither the OA nor the healthy marathon runners had intra-tendinous tophi. The sensitivity and specificity of US to detect tophi or aggregates were 69.6 and 92 %, respectively, tendon involvement at the lower limbs in gout is very frequent, particularly in the patellar tendon, and US possesses good sensitivity and specificity for detecting intra-tendinous tophi.

The aim of this study is to investigate the prevalence of subclinical ankle involvement by ultrasound in patients with rheumatoid arthritis (RA). The study was conducted on 216 patients with RA and 200 healthy sex- and age-matched controls. Patients with no history or clinical evidence of ankle involvement underwent US examination. For each ankle, tibio-talar (TT) joint, tibialis anterior (TA) tendon, extensor halux (EH) and extensor common (EC) tendons, tibialis posterior (TP) tendon, flexor common (FC) tendon and flexor hallux (FH) tendon, peroneous brevis (PB) and longus (PL) tendons, Achilles tendon (AT) and plantar fascia (PF) were assessed. The following abnormalities were recorded: synovitis, tenosynovitis, bursitis, enthesopathy and rupture. BMI, DAS28, RF ESR and CRP were also obtained. A total of 432 ankles of patients with RA and 400 ankles of healthy controls were assessed. In 188 (87%) patients with RA, US showed ankle abnormalities whereas, in control group, US found abnormalities in 57 (28.5 %) subjects (p = 0.01). The most frequent US abnormality in RA patients was TP tenosynovits (69/216) (31.9 %), followed by PL tenosynovitis (58/216) (26.9 %), TT synovitis (54/216) (25 %), PB tenosynovitis (51/216) (23.6 %), AT enthesopathy (41/216) (19 %) and AT bursitis (22/216) (10.2 %). In 118 RA patients out of 216 (54.6%), a positive PD was found. No statistically significant correlation was found between the US findings and age, disease duration, BMI, DAS28, RF, ESR and CRP. The present study provides evidence of the higher prevalence of subclinical ankle involvement in RA patients than in age- and gender-matched healthy controls identified by US.

AIM: Vascular damage and fibrotic process represent the pathophysiological hallmarks of systemic sclerosis (SSc). Peripheral microangiopathy can be early detected by nailfold videocapillaroscopy (NVC), whereas recent studies suggest that ultrasound real time elastosonography (US-RTE) can be a useful tool to evaluate the reduction of skin elasticity. The aim of our study was to investigate possible correlations between NVC microvascular alterations and finger tissue stiffness evaluated with US-RTE in SSc subjects. METHODS: 20 subjects (16 women and 4 men) who met the ACR criteria for SSc were recruited. All subjects underwent complete clinical examination, NVC and US-RTE evaluation. US-RTE was carried out on both the hands, at the level of the palmar surface of the distal phalanx of the fingers. RESULTS: 10 subjects showed limited disease subset (LSS) and 10 showed diffuse disease subset (DSS). Eight patients had 'Early/Active' NVC pattern and 12 had 'Late' NVC pattern. DSS subjects showed highest skin stiffness values when compared to both LSS (p = 0.03) and healthy subjects (p = 0.002). Multiple regression analysis shows an independent association between Late NVC pattern and skin stiffness (R2 = 0.24, p = 0.027). CONCLUSION: This study demonstrates, for the first time, a strong relationship between microvascular alterations and skin stiffness, evaluated with US-RTE, in SSc patients.

Over the years, ultrasound (US) has accumulated important evidence supporting its relevant role for the assessment of inflammatory processes of different rheumatologic diseases, as well as in the follow-up in assessing the response to different therapeutic approaches. This has been possible because of the increase in training, competency, and knowledge, as well as the rapid progress in the US technologies.Currently, some US machines can be equipped by sophisticated software modalities (i.e., 3-dimensional US, elastosonography, automated cardiovascular software, and fusion imaging) that can augment US traditional role as a safe, fast, and easy-to-perform modality and giving it new life and increased relevance in rheumatology. In this article, we evaluated the US developments, from conventional B-mode to more sophisticated technologies, and their potential clinical impact in the field of rheumatology.Three-dimensional US can improve the accuracy of the assessment of bone erosions and the quantification of power Doppler because of its multiplanar view including coronal, axial and sagital view. Elastosonography is still looking for its role in rheumatology. Preliminary works induce us to consider it as a promise tool for the assessment of tendon pathology and skin of patients with connective tissue disorders. The automated method for the measurement of carotid intima-media thickness permits a rapid and accurate assessment. The preliminary published data showed that it is reliable, and valid compared to the traditional method; they also support the future of rheumatologists as the direct operators in evaluating the cardiovascular risk in daily practice. Fusion imaging increases the diagnostic power of US, displaying simultaneously in the monitor, the US image, and the corresponding computed tomography/magnetic resonance imaging image. However, there are no sufficient data supporting its application in daily rheumatologic practice.

The First PANLAR Rheumatology Review Course was held in Barranquilla, Colombia, in April 2015. Researchers, rheumatologists, epidemiologists, and a variety of allied professionals and patients attended the meeting. The scientific program included plenary sessions and symposia delivered by renowned experts in the field, followed by an interactive forum of discussion during 2 days.A broad spectrum of topics was discussed, reflecting the current challenges and opportunities for diagnosis and treatment of rheumatoid arthritis (RA) in Latin America. The scientific program included not only traditional disease aspects, but also social implications, research projects, and educational characteristics, patient perspectives, and novel care models, emphasizing the need for training human resources and proposing unique approaches to RA health care in Latin America, therefore helping us to increase and improve the knowledge and understanding of the characteristics of this health condition in the region, thus promoting and encouraging equity, quality, and efficiency of RA health care.