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Most patients with psoriatic arthritis begin with cutaneous psoriasis, which is why all early detection strategies are based on screening in the dermatological consultation and referral to a rheu matologist. However, there are cases of patients who consult initially for musculoskeletal symptoms, mostly joint pain, regardless of family and/or personal history of psoriasis. This study aimed to esti mate the frequency of psoriatic arthritis in a cohort of patients who consulted for polyarthralgia and to determine the differential features, at the time of clinical presentation, in relation to both patients with final diagnosis other than psoriatic arthritis and patients with diagnosis of rheumatoid arthritis.Consecutive patients with polyarthralgia (including arthralgia of the hands) were included. Clinical examination, laboratory tests, ultrasound with power Doppler of both hands, and radiography of both hands and feet were performed at baseline. All patients were followed up and the definitive diagnosis of psoriatic arthritis was established.A total of 1055 were included, 88 (8.3%) ended with diagnosis of psoriatic arthritis. Diagnosis of psoriatic arthritis was positively associated with a family history of psoriasis (odds ratio=4.14), pso riasis (odds ratio=78.94), radiographic erosions (odds ratio=5.74), and ultrasound with at least 1 joint with positive power Doppler (odds ratio=7.11). In comparison with rheumatoid arthritis patients, diagnosis of psoriatic arthritis was positively associated with psoriasis (odds ratio=433.42) and family history of psoriasis (odds ratio=41.63). On the other hand, it was negatively associated with positivity, for both rheumatoid factor (odds ratio=0.03) and anti-cyclic citrullinated peptide antibodies (odds ratio=0.06).The frequency of psoriatic arthritis was 8.3% and was associated with a personal and/or family history of psoriasis, radiographic erosions, and inflammatory involvement by Power Doppler Ultrasound (PDUS). In comparison with rheumatoid arthritis patients, psoriatic arthritis was associated with a personal and/or family history of psoriasis, while the presence of both rheumatoid factor and/ or anti-cyclic citrullinated peptide antibodies was shown to be a protective factor for the diagnosis of psoriatic arthritis.

Objectives The aim of this study was to evaluate the performance of a comprehensive diagnosis program called "Reuma-check" for the diagnosis of axial spondyloarthritis (SpA) in patients with low back pain (LBP). Methods This is a cross-sectional study. Patients with LBP aged 18 years or older were preselected, and those with at least 1 SpA feature completed the circuit. They were referred after 2 strategies: education for orthopedists and a campaign on social networks. All patients underwent a clinical evaluation, laboratory testing, and imaging (including human leukocyte antigen B27 evaluation and magnetic resonance imaging). The diagnosis of axial SpA was established by an expert rheumatologist opinion. Time from onset of symptoms to "Reuma-check," time from patient referral to admission of the checkup, and time from "Reuma-check" to diagnosis were evaluated. Results A total of 175 of 246 patients were included, most of them came from the social media campaign (55%). Seventy-five (43%) of 175 patients were diagnosed as axial SpA. The median time from referral (or self-referral) to access to the program was 1.3 months. The median time from symptoms onset to access to the program was 31.7 months, and the median time from the performance of "Reuma-check" to final diagnosis was 2 weeks. Features associated with a diagnosis of axial SpA were as follows: inflammatory LBP (odds ratio [OR], 6.64; 95% confidence interval [CI], 1.6-28), clinical enthesopathy (OR, 4.56; 95% CI, 1.1-18.4), positive human leukocyte antigen B27 (OR, 23.02; 95% CI, 3.5-58), and positive magnetic resonance imaging (OR, 14.34; 95% CI, 3.5-58). Conclusions "Reuma-check" allowed a high frequency of axial SpA diagnosis and improved access to rapid diagnosis, shortening the time from referral to diagnosis with a shorter acquisition time for the ancillary studies. Patients with a final diagnosis of axial SpA presented distinctive features.

Introduction: Magnetic resonance imaging (MRI) is a fundamental diagnostic tool in axial spondyloarthritis, it has allowed us, unlike radiography, to diagnose this pathology much earlier. Objective: To estimate the percentage of correct answers in the recognition of SpA MRI lesions and theoretical knowledge, before and after performing an educational intervention. Estimate if the good performance in the tests is associated with individual characteristics of the doctors. Methods: A test was carried out with 10 questions (7 for image recognition and 3 for theoretical knowledge) before and after the development of an MRI image workshop in EspA in diferents cities in Argentina. The correct response number was considered before and after the workshop, and those who achieved more than 12 points between the two evaluations were considered good performance. The following physician characteristics were collected. Results: A total of 106 physicians were evaluated. The results of the tests (total 10 questions) before and after the workshop were 53% and 68% correct, respectively (p:0.000). 65% of the physicians achieved a good performance (more than 12 correct).

To evaluate the performance of the European League Against Rheumatism (EULAR) definition of arthralgias suspicious for progression to RA in patients with hand arthralgias and to estimate the added value of both auto-antibodies and ultrasound (US) with power Doppler (PD).Consecutive patients admitted for hand arthralgias to "Reuma-check" ® program were included. This program includes the following at baseline: clinical assessment, laboratory tests, US with PD of both hands, and radiography of both hands and feet. All patients were followed-up after baseline evaluation by their treating rheumatologists, and a definitive diagnosis of RA (ACR/EULAR 2010 criteria) was established or not.A total of 465 consecutive patients were included. During follow-up, 44 (9.4%) were diagnosed with RA. Mean of baseline EULAR features describing arthralgia suspicious for progression to RA was 4.1 in patients with final diagnosis of RA vs 2.3 in non-RA patients (p 0.0001). The AUC for the EULAR defined features describing arthralgia suspicious for progression to RA for the final diagnosis of RA was 0.7827, while adding US with PD, rheumatoid factor (RF), and anti-cyclic citrullinated peptide antibodies (ACPA) data, the AUC was 0.9172 (p 0.0001). In the multivariate regression logistic analysis, baseline features associated with a final diagnosis of RA were difficulty with making a fist, RF, ACPA, and US with PD.EULAR definition of arthralgia suspicious for progression to RA had an acceptable performance to predict the future development of RA and improves adding information of both RF, ACPA and US with PD data.Key Points• Clinically suspect arthralgia may trigger rheumatologists to monitor patients closely for an early diagnosis.• EULAR definition of arthralgia suspicious for progression to RA predicts future development of arthritis.• Auto-antibodies and ultrasound improve EULAR definition of arthralgia suspicious for progression to RA.

Background/Purpose: complex regional pain syndrome (CRPS) is a form of chronic pain that usually affects an arm or a leg. CRPS typically develops after an injury, a surgery, a stroke or a heart attack. The pain is out of proportion to the severity of the initial injury. CRPS is uncommon, and its cause isn’t clearly understood.

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.

BACKGROUND The prevalence of human leukocyte antigen B27 (HLA-B27) is variable around the world. Our objectives were to estimate the frequency of HLA-B27 in an Argentinian cohort of axial spondyloarthritis (axSpA), to evaluate the differences between HLA-B27-positive and HLA-B27-negative patients, and to analyze its performance as a diagnostic biomarker. METHODS Observational study including patients older than 18 years, with axSpA diagnosis assessed in a fast track program (Reuma-Check SpA). All patients underwent the following: blood tests, HLA-B27, sacroiliac images, and enthesitis ultrasound. Sociodemographic data and SpA symptoms were also collected. The clinical assessor was blinded to complementary studies. For the sensitivity and specificity analysis, patients with chronic low back pain without axSpA who performed the same circuit in the same period were used as control, paired 1:1 (sex and age). RESULTS One hundred fifty patients were included, 75 axSpA and 75 controls. The frequency of HLA-B27 was 43% (95% confidence interval [CI], 30-53). The differences between HLA-B27-positive and HLA-B27-negative patients were observed in age of low back pain onset (36 vs 46 years), BASFI (Bath Ankylosing Spondylitis Functional Index) (4 vs 5), and extra-articular SpA features such as uveitis and inflammatory bowel disease (29% vs 50%). When this frequency was compared (low back pain control group), the difference was 43% versus 9% (odds ratio, 7.7; 95% CI, 2.8-24), and HLA-B27 had a sensitivity of 43%, specificity of 91%, positive predictive value of 85%, negative predictive value of 58%, and likelihood ratio of 4.9 (95% CI, 3-8). CONCLUSIONS The frequency of HLA-B27 in axSpA was 43%; positive patients had an earlier age of onset (36), a higher BASFI, and more SpA features. For the diagnosis of SpA, HLA-B27 had a good specificity but low sensitivity.

Objective.To evaluate the diagnostic value of color Doppler ultrasound (CDUS) for the detection of sacroiliitis, in patients with inflammatory back pain (IBP).Methods.Consecutive patients with IBP and suspected axial spondyloarthritis (SpA), but without a definitive diagnosis, were included. Consecutive patients with defined SpA and axial involvement were included as a control group. All patients underwent clinical evaluation, magnetic resonance imaging (MRI), and CDUS of sacroiliac joints (SIJ) within the same week. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnosis of sacroiliitis by CDUS were calculated, using MRI as the gold standard.Results.There were 198 SIJ evaluated in 99 patients (36 with previous SpA). There were 61 men (61.6%), with a mean age of 39.8 years (SD 11.3) and median disease duration of 24 months (IQR 12–84). At the patient level, CDUS had a sensitivity of 63% (95% CI 48.7–75.7%) and a specificity of 89% (95% CI 76–96%). The PPV was 87.2% (95% CI 72.6–95.7%) and the NPV was 66.7% (95% CI 53.3–78.3%). At joint level, CDUS had a sensitivity of 60% (95% CI 49–70%) and a specificity of 93% (95% CI 88–98%). The PPV was 83% (95% CI 78–95%) and the NPV was 43% (95% CI 33–56%). The sensitivity of CDUS for the diagnosis of axial SpA was 54% (95% CI 36.6–71.2%), specificity was 82% (95% CI 63.1–93.9%), PPV was 79% (95% CI 57.8–92.9%), and NPV was 59% (95% CI 42.1–74.4%).Conclusion.CDUS showed adequate diagnostic properties for detection of sacroiliitis and is a useful tool in patients with IBP.

To the Editor: Reported data of axial involvement in psoriatic arthritis (PsA) are variable (25–70%). This variability is mainly linked to different ways of defining this feature. Gladman1 established that the prevalence of axial involvement in PsA was close to 50% and that it is associated with HLA-B27. Likewise, psoriasis (PsO) spondylitis, unlike ankylosing spondylitis (AS), is characterized by not having a greater preponderance of the male sex, greater skin involvement, and a less severe course.2 We carried out an observational, cross-sectional, single-center study. The objective of our study was to estimate the frequency of axial involvement in patients with a recent diagnosis of PsA in a rapid diagnostic circuit called Reuma-Check3 and to carry out a comprehensive characterization (clinical, laboratory, and images). We also aimed to analyze the effect of axial involvement on other manifestations, and finally, to compare all features with a group of patients with axial spondyloarthritis (axSpA), diagnosed in the same circuit (with the same evaluators and the same imaging and laboratory techniques) in the same period of time, who did not present current PsO or history of PsO. This observational study was approved by an institutional ethics committee and was conducted in accordance with the current Declaration …

Introducción: Los datos reportados sobre el compromiso axial de la Artritis psoriásica (APs) son variables (25 al 70%), esta frecuencia esta vinculada a las diferentes formas de definirla. Objetivos: Estimar la prevalencia de compromiso axial en un grupo de pacientes diagnosticados de APs en el circuito Reuma-Check, realizar una caracterización clínica, laboratorio e imágenes y analizar las diferencias entre los pacientes que la presentan. Métodos: Pacientes que fueron admitidos al programa Reuma-Check con síntomas músculo esqueléticos: artralgias/artritis, dactilitis o entesitis asociado a psoriasis o antecedentes familiares. Una vez diagnosticados se interrogaba sobre la presencia de síntomas axiales: lumbalgia de más de 3 meses asociado al menos a uno de los siguientes: BASDAI >4, maniobras sacroiliacas y características inflamatorias. Se realizaba un segundo Reuma-Check para el estudio completo del compromiso axial (imágenes, HLA B27, BASFI). Resultados: De 139 pacientes 73 (52%) fueron finalmente diagnosticados de APs, 33% presentaban compromiso axial clínico. Se observo (con respecto a los que no tenían compromiso axial) mayor presencia de manifestaciones no musculo esqueléticas como uveítis e enfermedad inflamatoria intestinal, 42 vs 12 % (p: 0,004), mayor numero de entesitis 0,5 vs 0 (p: 0,04), y un compromiso funcional (HAQ) mayor, 0,8 vs 0,5 (p: 0002). En el análisis multivariado la presencia de manifestaciones no músculo esqueléticas y MASES se asociaron en forma independiente con el compromiso axial. Conclusión: La prevalencia de síntomas axiales fue de 33%, las características fueron inflamatorias y con actividad por BASDAI. Los pacientes con síntomas axial presentaban características de APS más severas.

Background Magnetic resonance imaging (MRI) is a fundamental diagnostic tool in axial spondyloarthritis (SpA), allowing us an earlier diagnosis of the disease compared to radiography. Objective To compare the performance of a recognition test on SpA MRI lesions and theoretical knowledge, before and after carrying out an educational intervention (hands-on workshop). We also evaluated whether the successes in the tests were associated with the individual characteristics of the participants. Methods A test was carried out involving 10 questions (seven for image recognition and three for theoretical knowledge) before and after the attendance to an MRI workshop in SpA performed in different cities in Argentina. The number of correct answers was assessed before and after the workshop; good performance was defined as the achievement of 6 correct answers on average between the pre- and post-test. Participants' characteristics were collected. Results A total of 106 participants were evaluated. Average of correct answers before and after the workshop were 5.3 and 6.8, respectively (P = .0001); 65% of participants achieved good performance. Performance is not associated with the characteristics of trained physicians. Conclusion MRI training workshops in SpA allow rheumatologists to improve recognition of acute inflammatory and structural lesions. The long-term effects of such training need further evaluation.

Purpose: To investigate the performance of ultrasonography (US) for the detection of knee osteoarthritis (OA) in patients suffering from knee pain, compared to conventional radiographs. Methods: Cross-sectional study performed at a university teaching hospital. Consecutive patients complaining of unilateral or bilateral mechanical knee pain who signed an informed consent were included. All patients underwent simultaneously an ultrasonographic and a radiographic evaluation of the knee. Exclusion criteria were age under 18 years, prior diagnosis of knee OA, diagnosis of inflammatory arthritis, history of knee surgery or trauma, severe knee deformities, and corticosteroid injection within the last 2 months. The diagnostic properties of US for the detection of knee OA were evaluated using radiological data as the reference method. Evaluated test properties were sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the positive and negative likelihood ratio (LR+ and LR–). Results: Three-hundred twenty-two knees (281 patients) were included. Radiographic degenerative changes were present in 56.8% (183) of the evaluated knees. Regarding the diagnostic properties of the US, the presence of either osteophytes or the compromise of the femoral hyaline cartilage had the best sensitivity to detect OA (95%), with a NPV of 92% and a LR– of 0,07, while the combined identification of osteophytes and compromise of the femoral hyaline cartilage had the best specificity (94%), with 94% PPV and a LR+ of 13. Conclusion: US demonstrated an excellent sensitivity with an adequate specificity for the detection of radiographic knee OA.

Resumen Objetivos Describir los hallazgos ecograficos en pacientes con artritis reumatoide (AR) en remision clinica y evaluar la capacidad de la ecografia con Doppler de poder (DP) para reclasificar la actividad de la enfermedad en este grupo de pacientes. Material y metodos Se incluyeron pacientes consecutivos con diagnostico de AR (criterios ACR/EULAR 2010) en remision clinica por DAS28 ( Resultados Se incluyeron 86 pacientes, de los cuales 23 (26,7%) tuvieron al menos una articulacion con senal DP positiva. Un 13% de los pacientes fueron reclasificados hacia baja actividad de la enfermedad aplicando el ECO-DAS28 cuando se consideraron activas las articulaciones con senal DP grado ≥ 1, el 12% cuando se considero actividad una senal DP ≥ 2 y el 2% de los pacientes cuando se considero la senal DP igual a 3. Ningun paciente se reclasifico a un nivel de moderada o alta actividad. Conclusiones A pesar de encontrar actividad inflamatoria residual por ecografia en aproximadamente un cuarto de los pacientes con AR en remision clinica, solo un bajo porcentaje fue reclasificado a un estado de baja actividad de la enfermedad y ninguno a un nivel de moderada o alta, aplicando los ECO-DAS28 propuestos.

The aim of the present study was to describe the ultrasound (US) findings in patients with rheumatoid arthritis (RA) in clinical remission, and to evaluate the ability of power Doppler (PD) US to reclassify disease activity in these patients.We included consecutive patients with RA according to 2010 American College of Rheumatology/European League Against Rheumatism criteria, who were in clinical remission by the Disease Activity Score (DAS282.6). Twenty joints of both hands were assessed by US. PD signal was evaluated on a semi-quantitative scale from 0 to 3. Three different US-modified DAS28 (US-DAS28) were constructed, replacing the clinical swollen joint count by the PD US joint count using PD score ≥1, ≥2 or ≥3, respectively.Eighty-six patients were included. Twenty-three (26.7%) patients had at least one joint with abnormal US-positive PD signal. Thirteen percent of patients were reclassified to low disease activity by applying the US-DAS28 when joints were considered active with a PD signal ≥1; 12%, when a PD signal ≥2 was considered, and 2% of the patients were reclassified when a PD score of 3 was considered. No patients were reclassified to a level of moderate or high activity applying US-DAS28.Although around a quarter of patients with RA in clinical remission showed PD US features indicating residual activity, only a small percentage were reclassified to a state of low activity and none to a level of moderate or high activity, applying the proposed US-DAS28.

It has been shown that nail involvement in psoriasis is associated with systemic enthesopathy. Our objective was to evaluate the association of nail involvement and enthesopathy at distal interphalangeal joint (DIP) level in psoriasis (PsO) and psoriatic arthritis (PsA) patients.Consecutive patients (54 PsO and 56 PsA) seen at the outpatients clinic in this cross-sectional study were included. All patients underwent both clinical and ultrasound (US) assessment on the same day.US revealed enthesopathy in at least 1 DIP joint in 9 patients with PsO (17%, 95% CI: 8-29%) and in 18 patients with PsA (32%, 95% CI: 20-46%). US extensor tendon enthesopathy was detected in a higher proportion of fingers with clinical nail involvement compared with fingers without clinical nail involvement, both in PsO and PsA patients (61.2% vs 16.8%, p0.0001 and 60.1% vs 22%, p0.0001, respectively). Among patients with PsO, 20% (95% CI: 7-41%) and 14% (95% CI: 4-32%) of those with and without clinical nail involvement showed enthesopathy on US examination, respectively (p = 0.54). Among PsA patients, the prevalence of enthesopathy was 30% (95% CI: 15-49%) for patients with clinical nail involvement and 35% (95% CI: 17-56%) for those without nail involvement (p = 0.71).Nail disease was associated with DIP US enthesopathy. There was a significant increased prevalence of extensor tendon enthesopathy in fingers with involved nails both in PsO and PsA, although no association was found between nail involvement and extensor tendon enthesopathy at patients' level. These features might support the nail-entheseal pathogenesis theory at DIP level.

The aim of the present study was to determine the agreement between ultrasonography (US), magnetic resonance imaging (MRI), and conventional radiography (CR) in the detection of findings indicative of enthesopathy in spondyloarthritis (SpA) patients. A cross-sectional study was performed in 40 SpA patients. Heel entheses (Achilles tendon and plantar fascia) were bilaterally examined by US, MRI, and CR. The three imaging modalities were carried out by three independent operators blinded to the other imaging modality data. Soft tissue abnormalities indicative of enthesopathy as thickening, structural changes, and bursitis were assessed by both US and MRI, and cortical bone abnormalities indicative of enthesopathy as erosions and enthesophytes were assessed by the three imaging modalities. The unweighted kappa values between US and MRI were 0.80, 0.66, 0.69, 0.70, and 0.70 for thickening, structural changes, bursitis, enthesophytes, and bone erosions, respectively. With respect to the detection of enthesophytes, the unweighted kappa values between CR and both US and MRI were 0.78 and 0.76, respectively. At last, for the recognition of bone erosions, the unweighted kappa values between CR and both US and MRI were 0.38 and 0.45, respectively. Using MRI as standard reference method, US was more sensitive with respect to CR revealing bone erosions. The present study provides evidence about the high overall agreement between US and MRI for all abnormal comparable findings at entheseal level and between US, MRI, and CR for the detection of enthesophytes in SpA patients.

Objective.To evaluate components of the minimal disease activity (MDA) criteria in psoriatic arthritis (PsA).Methods.In patients achieving and not achieving MDA, fulfillment of each of the 7 criteria was evaluated.Results.Among 41 patients with MDA, 7.4% did not fulfill the tender/swollen joint count whereas 49% did not fulfill the skin criteria. Of the 42 patients not fulfilling MDA, 100%, 76.5%, and 65% did not fulfill the patient pain score, the patient’s global assessment, and the Psoriasis Area and Severity Index (PASI), respectively.Conclusion.A minority of patients with PsA fulfilling the MDA criteria presented active joints, but half had active skin. Visual analog scale scores and the PASI prevented patients from achieving MDA.

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.

Background Interstitial lung disease (ILD) is an extra-articular complication in rheumatoid arthritis (RA) that may lead to severe impairment of respiratory function. High-resolution computer tomography (HRCT) is the most common imaging technique used in the assessment of ILD. However, the costs and the ionising radiation may limit its use in routine practice. Recently, US is generating interesting data that may support its use and validity in the assessment of ILD in rheumatic diseases1,2. Objectives To investigate the correlation between lung US and HRCT findings in the assessment of ILD in patients with RA. Methods Patients with diagnosis of RA according to ACR 2010 classification criteria with respiratory symptoms and previous diagnosis of ILD by HRCT were included. Clinical examination, pulmonary function test (PFT) and lung US were performed in all patients. Lung US was performed by a rheumatologist expert in US who was blinded to clinical and HRCT data. Serologic tests (anti-CCP, ESR, RF, ANA) were taken. Lung US was performed in 14 intercostal spaces (IS) and quantified according the following semiquantitative scoring: grade 0=normal (≤5 B-lines); grade 1=mild (≥6 to≤15 B-lines); grade 2=moderate (≥16 to≤30 B-lines); and grade 3=marked (≥30 B-lines). The Warrick score (extension) was used to interpret the HRCT findings. Results A total of 32 patients with RA (25 women and 7 men) were included. Mean age was 59.37 (±SD 13.66) years, and the mean disease duration was 58.75 (±SD 52.52) months. Sixteen patients were smokers and 75% were positive to anti-CCP. Moreover, the mean of DAS-28 was 3.71 (±SD 1.01). A total 448 IS were assessed by US. Lung US was positive for ILD in 28 patients (87.5%). From those, 7 patients (21.8%) with severe ILD,12 patients (37.5%) with moderate, 9 patients (28.1%) with mild. Four patients (12.5%) showed normal lung US assessment. A significant linear correlation was found between the US score and the HRCT score (p Conclusions Our study demonstrates that lung US may be a potential tool for the assessment of ILD also in patients with RA. It can be adopted in future as a screening tool to use at moment of the first diagnosis of RA. References [1] Tardella M. Ultrasound in the Assessment of Pulmonary Fibrosis in Connective Tissue Disorders: Correlation with High-Resolution Computed Tomography. J Rheumatol2012;39:1641–7. [2] Margaritopoulos G. Comorbidities in interstitial lung diseases. Eur Respir Rev2017;26:1–15. Disclosure of Interest None declared

Ultrasound (US) is a noninvasive imaging technique that continues to gain interest among rheumatologists because of its undoubted utility for the assessment of a wide range of abnormalities in rheumatic diseases. It also has a great potential to be used at the time of consultation as an extension of the clinical examination.Current data demonstrate that the standard clinical approach could result in an insensitive assessment of some the different aspects of the various rheumatic diseases for which US has become a feasible and effective imaging modality that allows early detection of anatomical changes, careful guidance for the aspiration and/or local treatment, and short- and long-term therapy monitoring at the joint, tendon, enthesis, nail, and skin levels. The spectrum of pathological conditions for which US plays a crucial role continues to increase over time and includes rheumatoid arthritis, spondyloarthropathies, osteoarthritis, crystal-related arthropathies, connective tissue disorders, and vasculitis.It is expected that the inclusion of more longitudinal studies with a larger number of patients and more rigorous methodological approach will undoubtedly provide a better understanding of the significance of the abnormal US findings detected in order to provide the proper diagnostic and/or therapeutic approaches. In this article, we analyze the current potential applications of US in rheumatology and discuss the evidence supporting its use in the daily rheumatologic practice.

Background Hyperferritinemia is associated with severe inflammatory conditions, such as rheumatic diseases with systemic inflammatory responses, and multiorgan dysfunction syndromes. Objectives To determine which diseases are associated with hyperferritinemia in a tertiary hospital; to compare ferritin levels between these different entities and to evaluate relationship between levels of ferritin and mortality in these patients. Methods A retrospective study was carried out in which all patients over 18 years with at least one determination of serum ferritin equal to or greater than 1000 ng/ml were identified in the laboratory database of our hospital between 1/1/2006 and 6/30/2016. Corresponding electronic medical records were reviewed and demographic data and clinical data were collected. Mortality was assessed at the end of follow-up. Descriptive statistical analysis and logistic regression analysis were performed in order to identify variables associated with mortality. Results A total of 1979 patients were included, 1235 men (62.4%) with a mean age of 63.2 years (SD 17.2). Only 36 patients (1.8%) presented a rheumatologic diagnosis as the only cause of high levels of ferritin, with Still9s disease (n=8) and systemic Vasculitis (n=9) being the main diagnoses. Table 1 shows patients9 characteristics grouped according to whether the elevation of ferritin was associated with a rheumatic disease or not. Median serum ferritin and transferrin saturation in both groups were similar (see Table 1). Mortality was lower for rheumatologic causes (5.9% vs 37.2%, p Conclusions Rheumatic diseases, represents a very small percentage of the causes of elevation of ferritin above 1000 ng/ml, and were associated with lower mortality than the non-rheumatic causes. Serum ferritin levels were significantly associated with increased mortality regardless of the underlying cause. Disclosure of Interest None declared

The objective of this study is to evaluate the responsiveness to therapy change of a global ultrasound (US) assessment in the short-term monitoring of spondyloarthritis (SpA) patients with peripheral involvement. Consecutive SpA patients with both clinical peripheral involvement and active disease (initiating or changing therapy) were included. All patients underwent both clinical and US assessment in day entering the study and after 3 months of follow-up. Peripheral global US assessment included the recognition of abnormal inflammatory findings at joint, tendon, and entheseal level according to standardized scanning methods. A total of 34 patients completed both basal and 3-month follow-up assessments. Acute phase reactants, both erythrocyte sedimentation rate and C-reactive protein, tenderness (68) and swollen (66) joint counts, Bath Ankylosing Spondylitis Disease Activity Index and Health Assessment Questionnaire decreased significantly at 3-month follow-up. Total score for the global US assessment also decreased significantly between basal and 3-month follow-up assessment [mean difference, 12.33 (IC 95 %, 9.23-15.42); p 0.0001]. All individual component, joint, tendon, and enthesis scores, also showed a significant decrease during the follow-up period. A high degree of intra-observer reliability was found for the global US assessment (ICC [95 % CI]: 0.977 [0.961-0.993]). This global US assessment, including joints, tendons, and entheses, showed a good responsiveness to clinical changes and might be useful for monitoring SpA patients with peripheral involvement.

Cristian Quiroz1, Santiago Ruta1, Javier Rosa1, David A. Navarta1, Ricardo Garcia-Monaco2 and Enrique R. Soriano3. 1Rheumatology Unit, Internal Medical Services, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, 2Radiology and Imagenology Department, Hospital italiano de Buenos Aires, Buenos Aires, Argentina, 3Rheumatology Unit, Internal Medical Services, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano de Buenos Aires, and Fundacion PM Catoggio, Buenos Aires, Argentina.

Ultrasound (US) has become an important tool in the management of rheumatoid arthritis (RA) but it is time consuming in clinical practice. We compared 3 US indices (with different numbers of joints) with disease activity measured by the 28-Joint Disease Activity Score (DAS28) in order to find the most parsimonious index still useful in clinical practice.Sixty consecutive RA patients were included. The DAS28 score was calculated by the attending rheumatologist, and later in the day, they underwent US examination by another rheumatologist trained in US (bilateral gray-scale and power Doppler examination of the wrist and metacarpophalangeal and proximal interphalangeal joints). Three different US indices were constructed: index A (22 joints), index B (10 joints), and index C (6 joints).All 3 US indices were significantly higher in patients with active disease versus inactive disease (P0.05 for all 3). Ultrasound index C showed the best correlation with DAS28 (rho = 0.5020, P0.0001) and a very good discriminative value for moderate to high disease activity (DAS283.2) and for absence of remission (DAS282.6) (areas under receiver operating characteristic curve = 0.75 and 0.80, respectively). A cutoff value of 3 in US index C showed sensitivity of 88.89% and specificity of 66.67% for absence of remission. Correlation between the 3 US indices was excellent.A US index of 6 joints (both wrists and second and third metacarpophalangeal joints bilaterally) correlated well with disease activity measured by DAS28 and may be used to evaluate RA patients in daily practice.

Psoriatic arthritis (PsA) is an inflammatory disease with potential involvement of both peripheral and axial skeleton which has variable clinical course and several degrees of severity.

This study aimed to perform an overview of how ultrasound (US) is being used, implemented, and applied in rheumatologic centers in Latin America (LA). A retrospective, multicenter 1-year experience study was undertaken. Eighteen centers from eight countries were involved. The following information were collected: demographic data, indication to perform an US examination, physician that required the examination, and the anatomical region required for the examination. A total of 7167 patients underwent an US examination. The request for US examinations came most frequently from their own institution (5981 (83.45 %)) than from external referral (1186 (16.55 %)). The services that more frequently requested an US examination were rheumatology 5154 (71.91 %), followed by orthopedic 1016 (14.18 %), and rehabilitation 375 (5.23 %). The most frequently scanned area was the shoulder in 1908 cases (26.62 %), followed by hand 1754 (24.47 %), knee 1518 (21.18 %), ankle 574 (8.01 %), and wrist 394 (5.50 %). Osteoarthritis was the most common disease assessed (2279 patients (31.8 %)), followed by rheumatoid arthritis (2125 patients (29.65 %)), psoriatic arthritis (869 patients (12.1 %)), painful shoulder syndrome (545 (7.6 %)), connective tissue disorders (systemic sclerosis 339 (4.7 %), polymyositis/dermatomyositis 107 (1.4 %), Sjögren’s syndrome 60 (0.8 %), and systemic lupus erythematosus 57 (0.8 %)). US evaluation was more frequently requested for diagnostic purposes (3981 (55.5 %)) compared to follow-up studies (2649 (36.9 %)), research protocols (339 (4.73 %)), and invasive guided procedures (198 (2.76 %)). US registered increasing applications in rheumatology and highlighted its positive impact in daily clinical practice. US increases the accuracy of the musculoskeletal clinical examination, influence the diagnosis, and the disease management. © 2016, International League of Associations for Rheumatology (ILAR).

Objective. The present study was aimed at testing the ability of a rheumatologist without experience in ultrasound (US) who attended an intensive 4-week training programme focused on US assessing bone erosions in the hands and feet in patients with RA. Methods. Twenty patients diagnosed with RA according to the ACR criteria were included in the study. All US examinations were performed bilaterally by two investigators (with different experience in the field of musculoskeletal US) at the following sites: the dorsal, lateral and volar aspect of the second metacarpal, ulnar and fifth metatarsal head; and the dorsal and volar aspect of the third metacarpal and second proximal heads. Each quadrant was scanning in longitudinal and transverse scans for assessing the qualitative, semiquantitative and quantitative US findings indicative of bone erosions according the OMERACT preliminary definition. Results. Both k-values and overall agreement percentages of qualitative and semiquantitative assessments showed moderate to excellent agreement between the two investigators. Similar results were obtained for the quantitative assessment with the concordance correlation coefficient value always significant. The only exception was the volar aspects, in particular those of the fifth metatarsal head. Conclusion. Our study suggests that after a 4-week dedicated training programme, a rheumatologist without experience in US is able to detect and score bone erosions in the hands and feet of patients with RA.

Objective To develop guidelines for Musculoskeletal Ultrasound (MSKUS) training for rheumatologists in the Americas. Methods A total of 25 Rheumatologists from 19 countries of the American Continent participated in a consensus-based interactive process (Delphi method) using 2 consecutive electronic questionnaires. The first questionnaire included the following: the relevance of organizing courses to teach MSKUS to Rheumatologists, the determination of the most effective educational course models, the trainee levels, the educational objectives, the requirements for passing the course(s), the course venues, the number of course participants per instructor, and the percentage of time spent in hands-on sessions. The second questionnaire consisted of questions that did not achieve consensus (>65%) in the first questionnaire, topics, and pathologies to be covered at each course MSKUS level. Results General consensus was obtained for MSKUS courses to be divided into 3 educational levels: basic, intermediate, and advanced. These courses should be taught using a theoretical-didactic and hands-on model. In addition, the group established the minimum requirements for attending and passing each MSKUS course level, the ideal number of course participants per instructor (4 participants/instructor), and the specific topics and musculoskeletal pathologies to be covered. In the same manner, the group concluded that 60% to 70% of course time should be focused on hands-on sessions. Conclusion A multinational group of MSKUS sonographers using a consensus-based questionnaire (Delphi method) established the first recommendations and guidelines for MSKUS course training in the Americas. Pan-American League of Associations for Rheumatology urges that these guidelines and recommendations be adopted in the future by both national and regional institutions in the American continent involved in the training of Rheumatologists for the performance of MSKUS.

The objective of this study was to evaluate the sensitivity and specificity of ultrasound (US) and conventional radiography (CR) for the detection of calcium pyrophosphate (CPP) crystals in patients with knee effusion. Consecutive patients ≥50 years old with knee effusion were included. All patients underwent arthrocentesis with aspiration of synovial fluid (SF) and subsequent analysis of CPP crystals using plain light and polarizing light microscopy. US and CR of the involved knee were performed immediately after arthrocentesis. CR results were read by an experienced rheumatologist, searching for chondrocalcinosis. US examinations were carried out by an experienced rheumatologist blinded to all clinical and imaging data. The following US abnormal findings were considered indicative of CPP crystals deposition (CPPD): (1) hyperechoic bands within the femoral hyaline cartilage layer, and (2) hyperechoic sparkling spots in meniscal fibrocartilage. A total of 75 knees were evaluated in the same number of patients. Analysis of SF revealed CPP crystals in 15 out of 75 (20 %) knees: all (10) patients with previous diagnosis of CPPD, 3 patients with previous diagnosis of primary knee osteoarthritis (OA) and 2 patients without previous definitive diagnosis of a rheumatic condition. Using SF analysis as reference method, sensitivity and specificity for US findings was 60 and 96.7 %, respectively, while CR showed a sensitivity of 40 % and a specificity of 83.3 %. US results showed high specificity with acceptable sensitivity to detect CPP crystals in patients with knee effusion. Compared with CR, US results had better specificity and sensitivity. US may be used in daily rheumatologic practice when CPPD is suspected.

Remission criteria and activity indices used in rheumatoid arthritis (RA) are often applied in psoriatic arthritis (PsA). Some new indices have been specifically developed for PsA. Our objective was to evaluate the performance of different remission criteria and activity indices in PsA. This is a cross-sectional study that includes consecutive patients with PsA. Information necessary to complete the following indices was captured: Composite Psoriatic Disease Activity Index (CPDAI), Psoriatic Arthritis Screening and Evaluation (PASE), Disease Activity Index for Psoriatic Arthritis (DAPSA), Disease Activity Score in 28 Joints (DAS28), Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI), and American College of Rheumatology and European League Against Rheumatism (ACR/EULAR) Boolean RA remission criteria. Patients were classified according to activity categories (remission, low, medium, or high disease activity). Correlation between indices was established. Fifty-five patients were included. Mean age was 53 years (SD = 12), and 35 (63.6 %) were males. Mean PsA disease duration was 5.9 years (SD = 8.5), and mean psoriasis duration was 15.9 (SD = 12.6). We found important differences in the percentage of patients classified as in remission by applying different remission criteria: DAS28 = 33 % (95 % confidence interval (CI) 20–45) vs ACR/EULAR = 4 % (95 % CI 1–17). Particularly, DAS28 and minimal disease activity seemed to be less stringent in PsA than the other indices. Of the specific PsA indices evaluated, CPDAI showed the poorest correlation with all the other activity measurements, although differences were not statistically significant in most cases. Disease activity in PsA is measured by many different indices. In spite they all showed good correlations between them, they classified different patients in different disease status.

The aim of our study was to investigate by ultrasound (US) the anatomical structures affected during a new episode of bilateral painful shoulder in patients with polymyalgia rheumatica (PMR) and rheumatoid arthritis (RA) and to compare the findings between these two conditions. PMR and RA patients complaining of new onset bilateral painful shoulder were included. Subjects without any known rheumatic condition with a new onset unilateral painful shoulder were assessed as a control group. US evaluation includes the depiction subacromial–subdeltoid (SAD) bursitis, long head biceps (LHB) tenosynovitis and/or gleno-humeral (GH) synovitis. Thirty patients with PMR, 30 with RA, and 60 controls were included for a total of 60 shoulders per group. Unilateral SAD bursitis and LHB tenosynovitis were significantly more frequent in patients with PMR when compared to those with RA (p

BACKGROUND Ultrasound has demonstrated to be a highly sensitive tool in the evaluation of entheses in spondyloarthropathy (SpA) patients and improves the ability of clinical examination to detect enthesopathy. OBJECTIVES The objectives of the study were to determine the prevalence of subclinical enthesopathy in SpA patients and to evaluate the reliability of ultrasound in the detection of abnormal findings indicative of enthesopathy. METHODS Six hundred lower-limb entheses were assessed in 60 SpA patients without known history of entheseal involvement. Sixty rheumatoid arthritis patients and 30 control subjects were included as control groups. Clinical examination and ultrasound were consecutively performed at each of the entheses to detect signs indicative of enthesopathy. Images from 20 SpA patients were stored and afterward evaluated to determine the reliability of abnormal ultrasound findings. RESULTS Ultrasound detected a high prevalence of enthesopathy in SpA patients with respect to both rheumatoid arthritis patients and control subjects (P < 0.001 for both comparisons). In SpA patients, clinical examination detected enthesopathy in 56 (9.3%) of 600 entheses. In the remainder 544 clinically asymptomatic entheses (90.7%) (not painful and not swollen), ultrasound detected in 331 (60.8%) at least 1 ultrasound sign of enthesopathy. The intrareader and interreader agreement for all ultrasound abnormal findings was good to excellent. CONCLUSION The present study demonstrates a higher sensitivity of ultrasound with respect to physical examination in the detection of signs indicative of enthesopathy in SpA patients with an adequate interreader and intrareader reliability. Further study is needed about the prognostic value of the ultrasound findings for predicting clinical onset of entheseal involvement.

The main aim of the present study was to determine the prevalence of subclinical entheseal involvement at lower limbs by ultrasound (US) in patients with psoriasis. The secondary aim was to determine the interobserver reliability of the Glasgow Ultrasound Enthesitis Scoring System (GUESS) and power Doppler (PD) technique in the assessment of enthesopathy.The study was conducted on 45 patients with psoriasis and 45 healthy sex- and age-matched controls. All patients with no clinical evidence of arthritis or enthesitis underwent an US examination. All US findings were identified according to GUESS. The interobserver reliability was calculated in 15 patients with psoriasis.A total of 450 entheses in 45 patients with psoriasis were evaluated by US. In 148 of 450 (32.9%) entheses, grayscale US found signs indicative of enthesopathy. In 4/450 (0.9%) entheses PD signal was detected. In the healthy population, US found signs of enthesopathy in 38 of 450 (8.4%) entheses and no PD signal was detected. The GUESS score was significantly higher in patients with psoriasis than in healthy controls (P0.0001). Both concordance correlation coefficient and unweighted κ values for US findings showed an excellent agreement (0.906 and 0.890, respectively).Our results indicate that both grayscale US and PD findings indicative of enthesopathy were more frequent in patients with psoriasis. The US ability to detect signs of subclinical enthesopathy should be the object of longitudinal investigations to define its value in predicting the clinical onset of psoriatic arthritis.

Chronic intestinal pseudo-obstruction (CIPO), a recently recognized manifestation of systemic lupus erythematosus (SLE) with only 23 cases reported in the English literature, may appear as a complication or as the initial presentation of SLE and usually occurs during the setting of an active lupus. The pathogenic mechanism in SLE is unknown. We describe four additional cases with clinical, radiological, and manometric features of CIPO. As SLE-related CIPO usually responds to treatment with high doses of corticosteroids and/or immunosuppressive and prokinetic agents, a high level of awareness of this complication is needed to avoid unnecessary surgical intervention.